






BffffB 

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A TEXT-BOOK 



OF 



MINOR SURGERY, 



INCLUDING 



BANDAGING, 



BY 

NEWMAN T. B. NOBLES, M. D., 

PROFESSOR OF SURGERY AT THE CLEVELAND HOMOEOPATHIC MEDICAL 
COLLEGE; ATTENDING SURGEON TO THE CLEVELAND CITY HOSPITAL, 
THE CLEVELAND HOMOEOPATHIC HOSPITAL, THE EAST END HOSPITAL, 
AND THE CHILDREN'S HOSPITAL. MEMBER OF THE AMERICAN INSTI- 
TUTE OF HOMOEOPATHY, THE CLEVELAND HOMOEOPATHIC SOCIETY, 
THE EASTERN OHIO HOMOEOPATHIC SOCIETY, AND THE OHIO STATE 
HOMOEOPATHIC MEDICAL SOCIETY. 



BOERICKE & TAFEL, 

PHILADELPHIA, PA. 
1903. 



THE LIBRARY OF 


CONGRESS, 


Two Copies Received 


JUN 5 


1903 


Copyright 


Entry 


classP as 


e\0& 

XXc No. 


rn 


JA 


COPY 



Copyrighted 1903, 

BY 
BOERICKE & TAFEL. 



H. B. COCHRAN, PRINTERS, 
LANCASTER, PA. 



PREFACE. 



The author has endeavored to give in the following pages the 
accepted facts in minor surgical technique, together with the 
methods of treatment which modern surgery has advanced. The 
writer full}' realizes that books upon the subject of surgery are 
plentiful, but the task was undertaken without misgivings, for it 
seems that the time must now be ripe for a book upon this sub- 
ject when one considers that there has not been printed a book of 
this nature in our school for twenty-one years. We thought it 
might be advantageous to offer this effort as a text-book for 
Homoeopathic students and have introduced subject material that 
will appeal to the general practitioner. 

The author has paid special attention to the aseptic and anti- 
septic methods of treating wounds, methods which originated 
within the past few years and have brought indescribable benefit 
to humanity. The details of this important subject are given 
and in every way possible the reader is urged to follow certain 
rules in a way that we hope will be considered as characterized by 
clearness and simplicity. 

No bibliography has been given and literary references have 
been largely omitted. This has been done purely for the sake 
of simplicity and because the book represents the result of sev- 
eral years of considerable experience in dispensaries, hospital 
practice and in college work. 

My grateful acknowledgments are due to Dr. W. B. Trego, 
Professor of Operative Surgery in the Cleveland Homoeopathic 
Medical College, for writing the chapter on Bandaging. 

To Messrs. W. B. Saunders & Co. I wish to express my sincei 
thanks for their kindly loan of the cuts used in this book. 

Thk Author. 



CONTENTS. 



PART I. 

s 

CHAPTER I. 

PAGES 
Sepsis, Asepsis, Antisepsis, I 7~i9 

CHAPTER II. 
The Aseptic and Antiseptic Agents, 20-24 

CHAPTER III. 
Preparation of Materials Used in Aseptic Operations, 25-32 

CHAPTER IV. 
Preparation for Aseptic Operation, 33~37 

CHAPTER V. 
General Considerations and the Technique of an Aseptic Operation, 38-42 

CHAPTER VI. 
The Technique of an Antiseptic Operation, 43-44 

CHAPTER VII. 
Aseptic Operations in a Dwelling Room, 45-48 

CHAPTER VIII. 
The Redressing ofWounds and Drainage. Wound Infection, . . . 49-52 

CHAPTER IX. 
Hemorrhage. Suture of Veins and Arteries, 53-56 

CHAPTER X. 
Shock, 67 



6 CONTENTS. 

CHAPTER XI. 

General Surgical Anaesthesia and Anaesthetics, 68-89 

Local Anaesthesia, • 82-86 

Subarachnoid Injections of Cocaine, 86-89 

CHAPTER XII. 
Minor Surgicai, Misceu,any. 

Lumbar Puncture, 90-92 

Aseptic Injections, 9 2_ 93 

Exploring Needle and Trocar, . 93 

Aspiration, 93~94 

Stomach Tube and Lavage, 95-96 

Stomach Pump, 95-96 

Vaccination, 96-97 

Skin Grafting, 97~99 

Super-heated Dry-air Baths, 100-102 

Passive Motion, 102-103 

Transfusion, 107-110 

Sub-cutaneous Injection of Saline Solution, 110-111 

Venesection, 103-110 

Counter-Irritation, - 112-115 

Operations on the Capillaries, 115-116 

Artificial Respiration, 117-120 

Treatment of the Apparently Drowned, 121-123 

Resuscitation after Suffocation, 124 

Heatstroke, 124-125 

Frost Bite, . 126-127 

Post-Operative Insanity, 127-128 

Removal of Tattoo Marks, . . . . 128 129 

Foreign Bodies in the Tissues, 130 

Morphine in Surgical Practice, 129-130 

Unconsciousness, 131-132 

Signs of Death, 132-133 

Plasters and Poultices, 133-136 

Sutures and Needles, 136-142 

CHAPTER XIII. 
Wounds. 

Infected Wounds 142-144 

Incised Wounds 144-145 

Punctured Wounds, 146-147 

Contused Wounds, 146 

Lacerated Wounds, - 147-149 

Gun-Shot Wounds, I49~ I 52 



1 



CONTENTS. 7 

Snake Bites, 152 

Dog Bites, 152-153 

CHAPTER XIV. 
Burns and Scalds. 

Burns I54-I57 

Powder Burns, 158 

Brush Burns, . 158 

Electrical Burns, 159-161 

X-Ray Burns, 161 

Burns Due to Chemicals, .S 161 

Injuries Due to Electricity, 162 

CHAPTER XV. 
Special Forms of Infections. 

Boils or Furuncle, 164-165 

Carbuncle, 165-167 

Erysipelas, 167-169 

Anthrax, 169-170 

Phlegmon, 1 70-1 71 

Abscess, 171-175 

Sinus and Fistula, 175-176 

CHAPTER XVI. 

Regional Minor Surgery. 

the head and neck. 

Wounds of the Scalp, 177-179 

Wounds of the Brain 179-182 

Foreign Bodies in the Eye, 182-183 

Wounds of the Conjunctiva, 183-184 

Wouuds of the Lids, • .... 184-185 

Carbuncle of the Lip, 185-186 

Peritonsillar Abscess, ... 186-187 

Ranula and Calculi, 187-188 

Alveolar Abscess 188-189 

Extraction of Teeth, ' 190-191 

Cancram Oris, 189 

Wounds of the Tongue, 192-193 

Stings and Bites of the Tongue, 193-194 

Foreign Bodies in the Tongue, 194-195 

Adherent Tongue, 195-197 

Acute Abscess of the Tongue, 197 

Burns and Scalds of the Tongue, 197-199 



8 CONTENTS . 

Intubation of the Larynx, 199-202 

Tracheotomy, 203-207 

Abscess of the Salivary Glands, 208-210 

Cut Throat, 210-212 

Abscess of the Neck. 212-213 

Foreign Bodies in the Nose, 213-214 

Rhinoliths 214 

Epistaxis, 214-217 

Foreign Bodies in the Ear, 207 

Excision of the Tonsils, 207-208 

Retro-Pharyngeal Abscess, 217-218 

Adenoid Growths, 218-221 

Foreign Bodies in the (Esophagus, 221-223 

Foreign Bodies in the Larynx and Trachea, 223-224 

1 
CHAPTER XVII. 

The Extremities. 

Wounds of Muscles and Tendons, 225-228 

Dislocation of Muscles and Tendons 228 

Teno-Synovitis, 228 

Wounds of Joints, 230-231 

Injuries of Nerves, 231-233 

Webbed Fingers, 233-234 

Sprains, 252-257 

Bursitis, . ... 235-238 

Thectitis, 238-239 

Paronychia, '. . 240-241 

Onychia, 241-242 

Palmar Abscess, 242-243 

Wounds of the Palmar Arch, .... 243-244 

Contraction of the Palmar Fascia, . . 244-245 

Trigger Finger, 246 

Warts, 234-235 

Sebaceous Cysts, . . 235 

Blistered Heels, 246-247 

Ingrowing Toe-Nail, 247-248 

Hammer-Toe, 248-249 

Corns, 251-252 

Bunions, 249-251 

CHAPTER XVIII. 
The Thorax. 

Concussion and Contusion of the Chest, 258-259 

Injuries of the Vessels of the Chest Wall, 259-260 



CONTENTS. 9 

Resection of a Rib, 260-261 

Aspiration of the Chest Wall, 261-262 

Strapping the Chest, 265 

CHAPTER XIX. 
The Abdomen. 

Injuries of the Abdomen, 263-265 

Wounds of the Abdominal Wall, 265-266 

Umbilical Hemorrhage, 266 

Tapping the Abdomen, 266 

s CHAPTER XX. 
The Urinary System. 

Catheterization, 267-270 

Retained Catheter, 270-271 

Urethral Injections, 271-272 

Urethral Instillations, 272-273 

Bougies and Sounds, . . . .' 274.-275 

Passing Sounds and Metallic Catheters, 273-274 

Passing the Female Catheter, . 275 

Irrigation of the Urethra, 275 

Irrigation of the Bladder, 276 

Irrigation of the Vagina, 277 

Strapping the Testicle, 280 

Urethral Hemorrhage, , 281 

Foreign Bodies in the Urethra, 278-279 

Stripping the Seminal Vesicles, 280 

Method of Increasing Size of the Penis, 279 

CHAPTER XXI. 

The Rectum. 

Foreign Bodies in the Rectum, 282 

Rectal Bougies, .... 282-283 

Wounds of the Rectum, 283 

Enemata, 283-285 



PART II. 



BANDAGING. 

Bandaging, 286 



ERRATA 



Page 43. The word Aseptic in the chapter title should read 
Antiseptic. 

Page 72. Arti on line fourteen should read anti. 

Page 75. Axomorphia on line one should read apomorphia. 

Page 81. Mental on line fourteen should read metal. 

Page 81. Diarrhea on line twenty-six should read diarrhoea. 

Page 82. Nirvanti on line thirty-two should read Nirvanin. 

Page 108. Retrctors on line sixteen should read retractors. 



MINOR SURGERY. 



CHAPTER I. 



SEPSIS, ASEPSIS AND ANTISEPSIS. 

There is perhaps no subject in the entire field of surgery with 
which it is of equal importance that the physician should be fa- 
miliar in both principles and practice as that of asepsis and anti- 
sepsis. It is appropriate for those who are reaping the benefits of 
great achievements and taking them as a matter of course, and 
who, notwithstanding, may have doubts as to the practical good 
of new methods, to review the past and contrast it with the pres- 
ent. It was Professor leister whose discoveries revolutionized 
surgery. In Glasgow, in 1864, his mortality in a series of opera- 
tions was 45.7 percent., largely from septic diseases. He then 
introduced some imperfect germicidal methods in his treatment 
and during operations. The next year his mortality fell to 15 
per cent. With more perfect antiseptic methods Lister's records, 
of course, improved. Professor Volkmann, before he adopted 
Lister's ideas, had a mortality record of 40 per cent, in compound 
fractures alone. After treatment with Lister's methods he had 
treated 135 compound fractures without losing a single patient. 

Nussbaum has shown that for forty years in the clinic under 
his direction, as well as that of his predecessors, the deaths from 
wound diseases were so common that patients with even the 
slightest injuries often succumbed to them; that erysipelas and 
abscesses were matters of daily occurrence; that 80 per cent, of 
all wounds were attacked with hospital gangrene, and that nearly 
all patients with compound fractures died. Such evidence might 
be easily multiplied, but as the subject has passed beyond the 
controversial stage it is unnecessary. Formerly, union after a 
2 



1 8 MINOR SURGKRY. 

breast amputation required one-fourth to one-half a year; healing 
of large amputations often required months. We now expect 
complete recovery in breast amputations in less than two weeks, 
and in major operations the patient stays not over three weeks in 
bed. 

Our whole conception and understanding of the treatment of 
wounds has been decidedly altered, and the modern surgeon does 
not respect any portion of the anatomy heretofore held sacred, 
but, reinforced by a careful surgical technique, he invades the 
visceral cavities and joints with an ever-decreasing mortality rec- 
ord. The principles of leister have been generally accepted and 
improved, and newer and better methods are being introduced. 
The ancients realized early that the elements of disease were 
transmitted through the air, and it was to the air itself that Iyister 
directed his first endeavors at asepsis. He sprayed the air, wound 
and surrounding tissues with a solution of carbolic acid, and ap- 
plied dressings soaked in the same agent, after which an occlusive 
dressing of some impermeable material was applied. At this time 
our knowledge of the germs contained in the air was very limited. 
This knowledge was increased by the labors of Professor Koch, 
who later showed that atmospheric bacteria were not as harmful 
as they were thought to be, and that wound infection was usually 
caused by micro-organisms being brought in direct contact with 
the wound. 

As accurate investigation has progressed the original views of 
leister regarding the importance of the bacteria of the air in 
wound infection are now much changed. The good qualities of 
his investigations, however, revolutionized surgery. Aseptic sur- 
gery is directed against the causes of putrefaction in wounds and 
their discharges. Putrefaction is a form of fermentation accom- 
panied by the development of offensive odors. When micro-or- 
ganisms or their products gain an entrance to the system and 
multiply and are absorbed, the result is shown by local and con- 
stitutional symptoms. This condition is termed Sepsis, and may 
be more or less severe, according to the character of the infecting 
micro-organisms and the amount of physiological resistance of the 
patient. 

Asepsis has for its object the thorough sterilization of the tis- 



SEPSIS, ASEPSIS AND ANTISEPSIS. 1 9 

sues and of all materials that are likely to come in contact with 
the wound, or even near it. It also aims to exclude bacteria by 
the aid of sterilized dressings. 

Antisepsis differs from asepsis in that by the former method the 
germicidal agents are used freely in and about the wounded 
tissues, and all objects brought in contact with the wound are 
strongly antiseptic. For clean wounds, that is, those made by 
the surgeon, the aseptic method is to be preferred; wounds made 
otherwise the antiseptic inethod is probably always indicated. 
Complete details of the two methods will be found in the succeed- 
ing chapters. 



CHAPTER II. 



THE ASEPTIC AND ANTISEPTIC AGENTS. 

A number of drugs and chemicals having germicidal qualities 
are being used to gain the desired end. The most commonly 
used are given. There are many others, but those below have 
been thoroughly tried. 

Carbolic acid is much used; it is inexpensive, and in a strong 
solution is very efficient. The strong solution is made as follows: 

Carbolic acid crystals i part. 

Water .20 parts. 

This solution may be used for sterilization of the skin, instru- 
ments and dressings. This solution is too strong for the cleansing 
of the hands, as it benumbs the sensibility. The objections to 
Carbolic acid are its offensive odor and the liability to produce 
poisoning. The former objections amount to nothing, and the 
latter is prevented by not permitting the solution to be confined 
within the tissues. A teaspoonful of Carbolic acid added to a 
pint of hot water is a quick way of making a 5 per cent, solution. 
The best ^ocal antidote for Carbolic acid is pure alcohol. 

That dilute solutions of Carbolic acid applied to the extremities 
for a number of hours may produce gangrene and total destruc- 
tion of the part is a fact of which the public at large and even 
many physicians are ignorant. Carbolic acid, once the favorite 
antiseptic among surgeons, has become a general household 
remedy for the treatment of slight wounds and bruises. During 
the past five years, at the Massachusetts General Hospital, eight- 
een cases of gangrene have been seen from this cause. 

An aqueous solution of Carbolic acid (3 to 5 per cent.) if ap- 
plied to an extremity, as the fingers or toes, for a number of 
hours in the form of a moist dressing or poultice, may produce 
gangrene and total destruction of the part. This result is not 
from compression, but simply from the action of the Carbolic acid. 



THE ASEPTIC AND ANTISEPTIC AGENTS. 21 

Numerous cases have been reported in which 3 per cent, and 2 
per cent, solutions have caused gangrene, which has resulted in 
amputation. 

The public must be taught to use some safer treatment. Moist 
dressings are often very soothing and helpful in slight injuries of 
the fingers or toes. A large part of the benefit to be derived 
from any form of moist dressing can be obtained by using boiled 
water on clean compresses. 

Bichloride of mercury has much to recommend it. The drug 
is cheap, efficient, inoffensive, more active, less penetrating. 
The solutions vary in strength from 1:500 to 1:10,000. The 
stronger solution is used for irrigation and disinfection of the 
hands and skin. For the irrigation of wounds a solution of 
1:2000 or 1:4000 is employed. Weaker solutions for the daily 
cleansing of wounds of larger size will prevent the constitutional 
effects that may be produced from the absorption of too strong 
solutions. Tablets containing different amounts of the salt can 
be procured, and these dissolved in water will enable the surgeon 
to get the desired strength. If large cavities are to be cleansed 
they should be carefully drained and the patient carefully watched 
to detect the symptoms of mercurial poisoning. Mercurial solu- 
tion should not be used for sterilizing instruments as it rusts 
them. 

Beta-Naphthol is used in a solution of 1 to 2,500 or 3,000. 
Kreolin in a 5 per cent, emulsion is a safe solution for the irriga- 
tion of large cavities, as it has no toxic effect. This chemical is 
almost universally used in obstetric practice and is highly recom- 
mended. 

Peroxide of hydrogen is a favorite antiseptic, and can be used 
in the original strength or diluted with water to various strengths. 
It is effective in the treatment of old sinuses and abscess cavities. 
Used full strength and in solution of 25 per cent, it is useful to 
cleanse any open cavity. It is especially useful in abdominal 
surgery if pus is present, and in the surgery of mucous mem- 
branes. This solution is best used by injection with a clean glass 
syringe. The action is shown by the effervescence of the fluid 
which dislodges and brings out of the cavity septic and necrotic 
products. The solution acts and cleanses mechanically, and 



22 MINOR SURGERY. 

should be used until the bubbles cease to arise. Hydrogen di- 
oxide is used the same as the Peroxide. 

Formaldehyde is a valuable antiseptic gas used for disinfection 
of rooms, clothing, etc. The gas is generated by a special ap- 
paratus. 

Formalin is a 40 per cent, solution of Formaldehyde in water, 
and has valuable antiseptic properties. It is especially useful in 
a 2 per cent, solution to disinfect instruments, and is being used 
in the treatment of wounds. It has some disadvantages in that 
some wounds are irritated by its presence. A 2 per cent, solu- 
tion will cause a superficial slough, and a 1 per cent, solution is 
quickly destructive of fresh granulation. No solution, however 
weak, ought to be applied to any surface which is expected to 
unite by primary union. 

Stitch-hole abscess along lines of union ought never to be 
washed out by it, nor ought it to be applied to surfaces that are 
expected to heal by granulations. By its effect upon the capil- 
lary circulation, or by its effect upon terminal nerves, solutions 
that appear safe for all other purposes have the power to arrest 
the repair process, and are therefore to be avoided in all cases in 
which one desires to promote this result. Subcutaneous fat 
appears to offer a very feeble resistance to the constringing effect 
of the solution. 

The slough caused by Formalin is very characteristic. It is 
tough and leathery, at first of a pearly whiteness, and on ex- 
posure to the air appears to oxidize into a firm, resistent surface 
of very nearly a black color. It is not cast off as other sloughs 
are, but will cling to the underlying surface indefinitely. 

Sulpho-carbolate of zinc is a strong antiseptic in a solution of 
30 to 40 grains to the ounce of water. In infected wounds and 
especially those due to wounds received at post mortems and in 
operations it is very useful. In such instances the fluid should 
be forced into the wound, and the wound then dressed with a 
moist bichloride dressing 1 to 2,000. 

Nosophen, an iodine compound, possesses germicidal proper- 
ties and is a useful substitute for Iodoform. It has the advantage 
over Iodoform of not being poisonous, and has an agreeable odor. 
It is employed for the same purpose as Iodoform, and is particu- 



THE ASEPTIC AND ANTISEPTIC AGENTS. 23 

larly useful as a dressing to chronic ulcers and operations about 
the rectum. 

Aristol is another iodine compound used as a substitute for 
Iodoform. 

Protargol and Largin are two silver salts used in strengths of 
^ to 2 per cent, as antiseptics. Their use is largely restricted 
to the urethra and mucous surfaces. 

Permanganate of potassium is empk^ed for washing the hands 
and irrigating wounds. It is very useful for irrigating the 
urethra and bladder in rto 1,000 and 1 to 3,000 solutions. 

Thiersch's fluid, composed of one grain Salicylic acid and six 
grains of Boric acid to an ounce of water, is largely employed for 
antiseptic purposes. The solution is bland and does not irritate 
the tissues. Compressed tablets can be kept on hand and the 
fluid made readily. It is especially useful in operations on the 
serous surfaces and on the mucous membrane of the eye, throat 
and urethra. It can be empk^ed in safety at all times and under 
all conditions. 

Boric acid in 5 per cent, solutions is used for nearly the same 
purposes as Thiersch's fluid, and is an acceptable antiseptic. 

Iodoform has been largely useful in the past as a common 
wound disinfectant and dressing, but on account of the peculiar 
penetrating odor that is generally offensive, the drug is gradually 
being discarded for some iodine compounds that have the useful 
properties of Iodoform and are minus the odor and irritating 
qualities. It is often used in operations about the rectum and 
vagina, and the powder is applied as a dressing in infected 
wounds. In operations in the cavities that have or will have 
post-operative foul discharges iodoform gauze packing is useful 
as an absorbent, and will help prevent sepsis by preventing the 
discharge from becoming foul. Iodoform collodion is made by 
adding fifty grains of Iodoform to one ounce of Collodion, and is 
a useful dressing in superficial wounds. An ethereal solution is 
made of 15 grains of Iodoform and one ounce of ether, and is 
used for small wounds. Iodoform emulsion used in the treatment 
of tubercular suppurative processes is composed as follows: 

Iodoform one drachm. 

Sterilized glycerine ... ten drachms. 



24 MINOR SURGERY. 

The toxic action of Iodoform is more pronounced in the aged 
and infants. 

Orthoform has the double qualities of being somewhat anti- 
septic and a powerful and lasting local anaesthetic. Orthoform 
acts in some cases as a local irritant, and in susceptible individu- 
als it may start an eczema. 

Ivysol is a soapy liquid that has an odor similar to that of 
Carbolic acid, but is less poisonous. It may be used in strengths 
of from ^ per cent, to i per cent. 

Dry and moist heat are commonly used agents for the destruc- 
tion of micro-organisms. Instruments and dressings can be 
boiled or baked for a few minutes and so rendered sterile . 

Gasoline is a valuable detergent, and may yet be found to be 
antiseptic. It is very inflammable. It should be used carefully 
about an exposed light. If it gets into cavities, such as the ears 
or eyes, it is irritating, just as chloroform or ether is. If applied 
to a surface where it can readily evaporate it gives a cooling, 
pleasant sensation. 

In subsequent dressing of wounds, if the dressings are adherent 
about line of incision or suture, a few drops of gasoline squeezed 
on the adherent dressing will enable it to be readily detached. 

If one wants to remove sutures from wound and they are 
masked by iodoform powder and exudations from the wound, 
gasoline on a wipe applied gently will clear the field. Gasoline 
dissolves iodoform and the exudation from wounds and then 
immediately evaporates, leaving a clean and dry surface. The 
sutures can readily be found and removed. 



CHAPTER III 



PREPARATION OF MATERIALS USED IN ASEPTIC 
OPERATIONS. 

Sponges. — Are the best agents to absorb rapidly blood or other 
fluids. Owing to imperfect methods of sterilization their use has 
been discarded in favor of gauze pledgets. The technique given 
below has been found effective, for it has been proven that 
sponges prepared in this way are absolutely sterile, and they will 
be found to have retained all their physical qualities, size, soft- 
ness, elasticity, power of absorption, etc. 

By using the following method sponges can be repeatedly ster- 
ilized by boiling: 

i . The sponges are freed from calcareous matter by immersion 
for twenty- four hours in 8 per cent, muriatic acid solution, and 
then thoroughly washed in water. 

2. They are then boiled for fifteen minutes or longer in the 
following solution: Potassium hydrate, i part; Tannic acid, 3 
parts; water, 100 parts. 

3. They are washed in water, carbolic acid or sublimate solu- 
tion until all of the Potassium-hydrate-tannic-acid mixture 
(which is of a dark-brown color) is removed. 

4. The sponges are preserved in a 5 per cent, carbolic acid 
solution. 

Sponges that have been used can be re-sterilized by washing 
them in water and then boiling them once more in the solution, 
etc. The solution can be used any number of times, as it does 
not deteriorate by boiling or by age. 

Gauze Pledgets, Pads or Wipers. — Are made of sterilized 
gauze folded upon itself in such a manner as to form squares of 
various sizes and thickness, dependent on the requirement of a 
special case. The cut edges of the gauze are turned in and 
stitched, so that loose threads will not become detached and re- 
main in the wound. Wipers for ordinary use are made two and 



26 MINOR SURGERY. 

one-half to three inches square, and comprise four or five thick- 
nesses of gauze. In deep cavities gauze pledgets should not be 
left in the wound unless a piece of tape of suitable length be con- 
nected with each and kept in view, the tape being held by a hem- 
ostatic forceps. From twenty to thirty pledgets should be pro- 
vided for an operation, and twice as many for an operation of 
much magnitude. Great care should be taken to remove loos- 
ened threads from these pieces of gauze, for if left behind in the 
wound they prolong the healing process. 

Gauze pledgets before using should be thoroughly sterilized by 
exposure to steam for half an hour, while wrapped loosely in a 
towel or enclosed in sterilizing cases. 

Not a few cases are on record where pledgets and sponges have 
been left behind in the abdominal cavity and other cavities, and 
the wound sutured, and many embarrassing complications have 
arisen. To prevent such a mistake, it is a good plan to have an 
assistant or nurse whose whole duty shall be to hand the pledgets 
or sponges to the operator, and to count these agents before the 
operation and when it is finished. The figures should be marked 
down to avoid mistake. If the figures do not tally the missing 
sponges must be found. 

Tupfers are small balls of sterilized cotton surrounded by ab- 
sorbent gauze. They are prepared for use in the same way and 
employed for the same purpose, and then, like the pledgets, 
thrown away. 

Catgut Ligatures. — Catgut is used largely as sutures and 
ligatures. Only the best that can be obtained should be used. 
For the ligation of vessels and closing up of dead spaces it is the 
most useful of agents. The disadvantages of its use are that it 
slips easily when tied, it is sterilized with difficulty, and cannot 
always be obtained. One of its good points is that it is readily 
absorbed by the tissues, and is the ideal suture in closed cavities. 
In preparing catgut for surgical use the principal object is to ren- 
der and keep it absolutely sterile. This is accomplished by mas- 
cerating and preserving the gut in some efficient antiseptic liquid 
or by subjecting it, while immersed in a suitable fluid, to a suffi- 
ciently high temperature, or by both methods combined. 

Many methods have been advanced for the sterilization of cat- 
gut. The one given below has been found satisfactory: 



PREPARATION OF MATERIALS. 27 

i. The catgut, twelve strands, is rolled in a figure-of-eight 
form, so that it can be slipped into a large test tube. 

2. Bring the catgut up to a temperature of 176 F., and hold it 
at this point for one hour. 

3. Place in Cumol, which must not be above 212 F., and hold 
it at this point for one hour. 

4. Pour off the Cumol, and either allow the heat of the sand 
bath to dry the catgut or transfer it to a hot-air oven, at a tem- 
perature of 212 F., for two hours. 

5. Transfer the rings with sterile forceps to the test tubes pre- 
viously sterilized, as in a laboratory. Small quantities should be 
placed in each tube so as to avoid repeated opening for use and 
exposure to infection. 

Chromicized catgut is used where the effect of catgut is to be 
prolonged. It is not so soluble and the effect of the suture or 
ligature is more lasting. A method used for preparing this kind 
of catgut is as follows: 

Tough catgut is first deprived of fat by being boiled with ether. 
It is then wound on bobbins of wood, as many strings being tied 
together as each bobbin will hold, the ends being secured in 
notches made in the bobbins. The latter are then weighted down 
by sinkers and completely immersed into a sufficient quantity of a 
solution prepared after the following formula: 

Potassium bichromate, 22^ gr. 

Water, 15 oz. 

Dissolve and then add, 

Glycerine, 2]/ 2 dr. 

Carbolic acid, 2^ dr. 

In this solution the bobbins are allowed to remain during thirty 
hours. They are then removed and the catgut at once wound 
upon frames of wood three feet long. It is now allowed to be- 
come dry at a temperature not exceeding 113 F., which will 
require a few days. When dry the gut is removed in pieces the 
length of the board, and the pieces are rolled into coils small 
enough to go into one ounce glycerine jelly jars, each coil being 
secured, if necessary, by two pieces of fine aluminum wire. It is 
finally sterilized by means of alcohol under pressure. 



28 MINOR SURGERY. 

Ligatures of catgut when prepared are put up in small, wide- 
mouthed glass receptacles, and can be used as desired. Both kinds 
of catgut can be procured already treated and ready for use. 
That put up in small closed glass tubes that are broken when 
needed is the best. 

Silk Sutures and Ligatures. — Silk has the advantage of 
being cheap, easily attained and sterilized, readily applied and 
remains firmly fixed if properly tied. It is rather too readily in- 
fected both within and without the wound, and its use often 
causes ' ' stitch abscess. " It is fitted especially for the tying of 
pedicles and other large masses of tissue. 

Silk is sterilized by boiling in a i per cent, aqueous solution of 
washing soda for ten minutes, or by steaming in a sterilizer for 
fifteen minutes. It can then be treated in skeins or while wound 
loosely on glass spools or bobbins. After washing out the soda 
by a few moments' immersion in pure boiling water ligatures can 
then be properly preserved in sterilized glass tubes plugged with 
cotton, or in wide-mouthed bottles containing alcohol or other 
proper antiseptic fluid. Silk should be prepared on each occasion 
to be strictly surgically clean. 

Silk when left in the tissues becomes encysted and does not 
often cause suppuration if properly prepared. 

Silk worm gut is used for sutures, and may be sterilized by 
boiling for fifteen minutes, or by placing it for one-half hour in a 
5 per cent, carbolic solution. Afterwards it should be kept in 
alcohol. 

Horse hair is used for ligatures and sutures in small wounds 
and delicate operations. It is also used for drainage in superficial 
wounds, a number of strands of the hair being placed in the 
wound and the ends allowed to project from one or both extremi- 
ties of the wound. Before being used it should be washed with 
soap and water and then soaked in a 5 per cent, carbolic acid 
solution or 1:1,000 bichloride solution for thirty minutes. 

Silver wire is desirable at times when a tension suture is re- 
quired. It is rendered sterile by boiling in a soda solution. 

Drainage tubes are made of rubber and glass of different sizes 
perforated at short intervals. The tubes should be kept in a 5 
per cent, carbolic solution, or if kept dry they should be washed 



PREPARATION OF MATERIALS. 29 

and sterilized by boiling water before being used. Drainage 
tubes should be fastened in position so they will not slip in or out 
of the wound. A thread of catgut or safety pin passed through 
the edge of the tube will serve to hold it in position. 

The protective and Mackintosh dressings are rarely used. The 
latter prevents proper evaporation and causes the dressings to 
become warm and moist, so becoming a fertile soil for germ 
development. 

Rubber tissue is thin, has a glazed surface and is useful as a 
protective following the operation for skin grafting. 

Rubber dam is more substantial than the rubber tissue, and 
like it, can be sterilized by soaking in a 5 per cent, solution of 
carbolic acid or of bichloride of mercury 1:1,000. 

Wet dressings are soaked with some fluid and covered with 
rubber tissue. They promote drainage and macerate the wound 
and the skin. The solution should be non-irritating. Goulard's 
solution or lead water, as it is called, is one of the best for the 
purpose. 

Dry dressing consists merely of the gauze placed next to the 
wound and covered by germ-proof substances. 

SOME MATERIALS USED IN SURGICAL DRESSINGS. 

The most important requirement of aseptic surgery as regards 
dressings is that the material used be free from pathogenic 
bacteria. 

Gauze. — For the direct covering and tamponing of wounds 
gauze is indispensable; being a fabric it is coherent and leaves no 
particles behind to irritate the wound and retard the healing 
process. Ordinary cheese cloth made absorbent by extracting the 
fat is a cheap and effective dressing. It may be prepared at home 
by boiling the gauze in a solution of washing soda in the propor- 
tion of one pound of soda to twenty yards of gauze, sufficient 
water being used to completely cover the material. Boil for half 
an hour and then rinse in several changes of water to get rid of 
the soda. It should afterwards be dried and baked in an oven 
until slightly scorched, and may then be wrapped in a clean sheet 
until it is to be used. A convenient way to avoid exposing the store 
to the possibility of infection each time the gauze is used is to put 



30 ' MINOR SURGERY. 

it up in packets from five to ten yards in each. In an emergency 
mosquito netting, old linen or cotton cloth thoroughly boiled will 
make a fair substitute for gauze. 

Bichloride Gauze. — Is prepared by boiling in the soda solu- 
tion, rinsed and dried. It is then immersed in a 1:1,000 bi- 
chloride of mercury solution for twenty-four hours. It is then 
wrung out with clean hands and packed in different lengths in 
air-tight jars. If dry gauze is desired it may be dried in an oven 
and packed in sterilized jars. Bichloride gauze should not be 
applied directly to the skin, especially that of a child, as it is 
very liable to cause an erythematous irritation. 

Iodoform Gauze. — Is prepared by soaking sterilized gauze in 
the following combination: 

Iodoform 5 parts. 

Glycerine 20 parts. 

Alcohol 70 parts. 

This makes a 5 per cent, iodoform gauze. When the gauze is 
of a uniform yellow color it is ready to be wrung out with clean 
hands and packed in aseptic jars with air-tight covers. 

Carbolized Gauze. — Sterilized gauze is used and prepared by 
soaking for twenty-fours in a mixture composed of — 

Resin 1 pint. 

Alcohol . . • 5 pints. 

Castor oil 24 ounces. 

Carbolic acid 12 ounces. 

It is then wrung out and packed as decribed above. 

Cotton. — Cotton which is quite universally popular and ser- 
viceable is not adapted for direct application to wounds. With 
its use the dressing becomes dry, packed and adherent, and can 
be removed only with difficulty. Its rapid power of absorption 
makes cotton an important material for sponging. Cotton pos- 
sesses the virtue of special softness and pliability, besides being so 
simple and easy of application. Absorbent cotton is used to fill 
out dressings, as a protective to take the place of sponges during 
operations, and for many other purposes. The material is pre- 
pared from ordinary cotton, which is boiled in a strong soda solu- 
tion to remove the oily matter it contains. 



PREPARATION OF MATERIALS. 3 1 

Bichloride cotton is prepared by soaking absorbent cotton in a 
1:1,000 bichloride solution for twenty- four hours, drying and 
packing in air-tight cans. Absorbent cotton is also treated with 
solutions of carbolic acid, salicylic acid and boric acid, and when 
so prepared form much used materials in surgical dressings because 
of the great absorbing power and elastic properties. 

Sterilized cotton is prepared by placing absorbent cotton in a 
steam sterilizer and allowing it to remain for two hours. Cotton 
is largely employed in the treatment of fractures to pad splints 
and to relieve bon} r prorhinences from pressure. 

Compressed Moss. — This is a most desirable dressing material 
as its absorbent power is five times as great as gauze. It may be 
used after being put into gauze bags or compressed into a tablet- 
like shape. It makes an ideal splint when compressed into a 
board of thick size. After being dipped into water it adapts 
itself to the contours of the body like a plaster-of- Paris splint, 
over which moss board possesses the great advantage of being 
absorbent and much lighter. In compound fractures it is espe- 
cially valuable, for should the discharges exceed the absorbent 
power of the gauze directly covering the wound, the moss splint 
takes up the superfluous discharge without impairing the useful- 
ness of the moss as an immobilizing factor. It also dries con- 
stantly while absorbing at the same time. The price of moss 
board is very low. 

Lint, oakum, wood-wool, oiled silk or muslin, parchment paper 
are also useful in dressing wounds. 

Bandages should be kept on hand in large quantities. They 
can be easily sterilized in steam. Various lengths and widths are 
required, and they should consist of common absorbent gauze, 
starched gauze, muslin or of Canton flannel. 

Compresses are prepared by folding any of the above-mentioned 
dressing materials upon themselves so as to form firm masses of 
different sizes. Compresses are used where pressure is required, 
as in the treatment of fractures and hemorrhage. 

Tampons. — Are used as compresses folded to cause pressure 
and as vehicles to carry medicinal agents to various cavities or 
parts of the anatomy. Tampons are generally made of the differ- 
ent medicated gauzes. Tampons of wool to which a string is 



32 MINOR SURGERY. 

attached are especially useful to the uterus for inflammatory con- 
ditions, and tampons of gauze are used for controlling hemor- 
rhage from any cavity. In the later conditions the tampons are 
applied by packing the strips of gauze into the cavity with dress- 
ing forceps, and when the cavity is filled a folded compress is 
applied and held in place by a firmly applied bandage. Dry 
tampons should be used in cavities where there is a tendency to 
hemorrhage, and moist tampons where it is necessary to effect 
good drainage of the part. 

Tent. — A tent is employed to keep wounds open and as an aid 
to drainage. It is made by rolling into a cigar-shaped mass a 
piece of sterile or antiseptic gauze. 

Retractors are used to retract the soft parts in amputations 
and to prevent their injury by the saw in the division of bone. 
The cloth retractor is made of linen or muslin, according to 
the size of the limb to which it is applied. If for one bone, one 
extremity should be torn partially through the middle into two 
strips. The split portion is placed about the bone, the tails folded 
across each other, and by making traction On the sound end and 
the folded tails the soft tissues are pulled back from danger of 
injury. When two bones are to be sawed through one extremity 
of the retractor should be torn into three strips, the middle one 
for use between the bones, the remaining ones to be carried 
around them. 

A special metal retractor has been devised for use during 
amputations at the thigh and arm. 



CHAPTER IV. 



PREPARATION FOR ASEPTIC OPERATION. 

Preparation of Room for Operation. — When obliged to 
operate in a private home^it is best to select a room that has some 
of the conditions which are found in a hospital operating room. 
A room that is well lighted and with a water supply near at hand 
is best. If there is time it is well to remove articles of furniture, 
ornaments, curtains, pictures, rugs, and even the carpet. Tack- 
ing sheets over the floor covering or sprinkling the same with 
water will settle dust and help to prevent infection. Clean towels 
and clean sheets should be spread upon all pieces of furniture 




Fig. i. Portable Sterilizer. 

which are likely to come in contact with the operator or his as- 
sistant, or with anything which may touch the patient. Soap 
smeared over the window-panes will discourage prying neighbors, 
while it does not interfere with the entrance of light. If possible 
the walls and ceilings should be cleaned and the room fumigated 
with a formaldehyde lamp. 

Clothing of Operator and Assistants. — The surgeon, as- 
sistants and nurses should wear suits of duck or linen, or gowns 
which may be sterilized by exposure to dry heat or steam. They 
should also wear skull caps or a piece of folded muslin tied firmly 
about the head, covering the entire scalp. Canvas slippers may 
be worn. The operating suits should be changed after each op- 
eration and fresh ones worn. . In an emergency a folded clean 
3 



34 



MINOR SURGERY. 



sheet wrapped about the body, held in place by strips of bandage, 
makes a good gown. Towels pinned about the .shoulders and 
upper arms add to its usefulness. 

In operations where there is apt to be much hemorrhage or dis- 
charge it is convenient to wear, under the linen gowns, rubber 
aprons to prevent soiling. These aprons can be rinsed in bichlo- 
ride solution and worn over a duck suit. 

Sterilization of the Hands and Forearms. — The skin 
cannot be rendered absolutely sterile, but different methods are 
recommended that aid in procuring cleanliness. The surgeon 
should not wear rings. The nails should be cut short and 
rounded. Nail-files should be avoided, as they form irregular 
surfaces from which microbes cannot so easily be removed as 





Fig. 2. (aO Gas heated apparatus for 
sterilizing instruments. 



(b) Wire basket. 



from a sharp cut done with scissors. Special attention should be 
paid to cleansing of the finger-nails with a sterilized metal nail- 
cleaner. The subungal spaces and finger ends should be, at the 
last moment, wiped thoroughly with pledgets of cotton soaked in 
alcohol. The hands and forearms should be rubbed energetically 
with a sterile skin brush and green soap for at least ten minutes, 
then covering them with a hot saturated solution of permanga- 
nate of potash until they are deeply stained. After this the 
hands should be immersed and moved about in a hot saturated 
solution of oxalic acid until all the coloring is removed; they 
should then be dipped in milk of lime or sterile plain water to 
wash off the oxalic acid. 

A practicable and effective method is to wash and scrub care- 



PREPARATION FOR ASEPTIC OPERATION, 



35 



fully the arms and hands with green soap and water. During the 
use of this a half-teaspoonful or more of common powdered mus- 
tard is thoroughly rubbed into the skin, or the washing with 
mustard may be a separate affair. The mustard is then washed 
off with sterile water. This method has been thoroughly tested 
and may be used on that region of the patient's body which is to 
be operated. The part is scrubbed with the combination while, 
after shaving the parts, fine mustard is again rubbed in and then 
carefully washed off witr^ sterile water. 

A simple method is to scrub the hands for ten minutes with 
green soap and water. This is followed by washing and rubbing 





Fig. 3. Steam sterilizer for dressings. 



(a) Exterior 



(b) Cross section. 



with a bichloride solution (1:1000) for another minute. During 
the operation the hands are frequently rinsed in the same solu- 
tion. 

Rubber, cotton, silk and flannel gloves, rubber finger-cots, rub- 
ber sleeves, are widely used and good reports given as to their 
efficiency in preventing infection. The sense of touch is some- 
what impaired, though experience overcomes this. Rubber 
gloves and sleeves may be sterilized by washing with soap and 
water, and immersion in a 1 to 1,000 solution of bichloride of 
Mercury. Cotton gloves can be sterilized by boiling or by dry 
heat. 



36 MINOR SURGERY. 

Sterilization of the Skin. — The patient should have one or 
more warm baths. The field of operation and its vicinity must 
be shaved if there is the slightest evidence of the presence of hair: 
the region must next be scrubbed with soap and hot water and 
afterward with alcohol and bichloride of Mercury solution, i to 
500. Sulphuric ether poured over the area to be operated is an 
additional safeguard. 

It is often advisable, in preparing a patient for an operation, 
such as laparotomy, to cover the field of operation with a poultice 
of green soap on the evening preceding the day of operation, after 
prophylactic disinfection has been carried out. After the soap 
has remained for three hours it is scrubbed away, thus removing 
as much epithelium as possible. A towel saturated with a strong 
bichloride solution is then applied, and is allowed to remain until 
shortly before the operation. Compresses of a one per cent, for- 
malin solution may also be used, the solution being kept in con- 
tact with the skin for twenty-four to thirty-six hours, the com- 
press changed every twelve hours. 

Mucous membranes cannot be disinfected as thoroughly as the 
skin. Antiseptic solutions are not well borne and irritate the 
membranes. Mechanical cleansing must be resorted to as the 
most effective agent to the desired end. 

Sterilization of the Vagina. — The external genitalia must 
be scrubbed and shaved. The organ must be wiped out thor- 
oughly with a pad dipped in green soap and irrigated with bi- 
chloride solution, salt solution or boracic acid solution. 

Sterilization of the Bladder. — Complete disinfection of 
the bladder is an impossibility. In a healthy bladder no microbes 
are found, while in disease they are seldom absent. Microbes 
may enter the bladder from the kidneys, but in the great majority 
of cases they are carried into the bladder by instruments used in 
surgical operations or examinations. Therefore none but per- 
fectly aseptic catheters and sounds should be used. 

As the healthy urethra always harbors micro-organisms, this 
canal must be cleansed before passing instruments. Irrigation 
with Permanganate of potassium solution 1 to 3,000 by the recur- 
rent stream of an irrigation catheter is effective. Boric acid and 
Thiersch's solutions answer the purpose. Either of these solu- 
tions can be forced into the bladder by hydrostatic pressure, the 



PREPARATION FOR ASEPTIC OPERATION. 37 

patient emptying the bladder when a sensation of fulness is ex- 
perienced. This procedure may be repeated several times. 
While under an anaesthetic from four to six ounces of the solu- 
tion can be injected and then withdrawn. The urine may be 
somewhat disinfected by administering 1 or 2 drachms of Salol 
within twenty- four hours of the operation, or Urotropin 7 grains 
t. i. d. for several days preceding operation. These drugs are 
also useful previous to operations on the kidneys. 

Sterilization of the Rectum. — In operations on the rectum 
laxatives should be freely given and enemas administered. In- 
jections with the long colon tube are also necessary. The region 
about the anus should be shaved and the whole area thoroughly 
scrubbed. After the anaesthetic has been given the sphincter 
ani is stretched with the thumbs or speculum and the rectum 
irrigated with a boric acid or Thiersch solution, going up into the 
sigmoid flexure. A tampon of sterile gauze with a string attached 
should be packed into the rectum above the seat of operation, and 
the rectum again irrigated. After the operation the tampon 
should be removed by means of the string. 

Sterilization of the Feet. — When there is time, for three 
successive days they must be given a bath, which is to be fol- 
lowed immediately by a thorough scrubbing with a bichloride 
solution, 1 to 500. A green soap poultice is then applied. The 
next day the bathing and scrubbing is repeated. If these pro- 
cedures are carried out for three days the hypertrophied epidermis 
will become macerated and easily wiped off. The same method 
is useful even in a few hours previous to operating. 

Sterilization of Instruments. — All instruments which come 
in contact with wounds require the strictest aseptic cleanliness. 
All metal instruments are the best. A simple and effective 
method is as follows: The instruments are laid in a clean cooking 
vessel and water (warm if possible) is poured over in quantities 
to submerge them, then about a teaspoonful of pulverized sal soda 
to the quart of water is thrown in and the vessel placed on the 
fire. In ten or fifteen minutes the sterilization is complete, and 
the vessel with its contents is then cooled by setting it into a pan 
of cold water. Even in large operations this method can be used. 
Knives and scissors had best be sterilized by being placed in 
strong solutions of Carbolic Acid and Fomalin. 



CHAPTER V. 



GENERAL CONSIDERATION AND THE TECHNIQUE 
OF AN ASEPTIC OPERATION. 

Before a surgeon performs an operation of any magnitude, and 
one where a general anaesthetic is to be given, the patient should 
have a thorough physical examination. This is of importance, in 
that the future results will often be governed by the knowledge 
gained from such an examination. The sex, age, occupation of 
the patient, and if he be in shock should be considered. The 
condition of the internal organs of importance and blood vessels 
should be ascertained. There may be some condition undermin- 
ing the constitution, such as anaemia, insanity, tuberculosis, 
haemophilia, malaria, rheumatism, syphilis, glycosuria, that will 
have a decided effect on the results of operation. 

The operator should consider whether he personally has the 
essential requirements necessary to the proper performance of an 
operation. He should be perfectly familiar with the anatomy of 
the parts, and have a knowledge of the results of the operation 
to be performed. He should run over in his mind the emergen- 
cies liable to occur and possible complications. He should be 
familiar with general anaesthesia and the treatment of hemor- 
rhage. Before the operation an inspection of all the materials to 
be used as regards quality and quantity must be made. Profi- 
cient assistants, suitably attired, should be in attendance. 

What is most important as regards the future welfare of both 
patient and surgeon is that the operator ought not deliberately 
undertake to perform such operations as he knows to be beyond 
his skill and experience. In ' ' acute surgery ' ' and emergencies 
one may attempt to save life at almost any risk, but the indis- 
criminate use of the knife is to be discouraged. 

The assistants of the surgeon, when properly trained, relieve 
their chief of much detail work. Each one must attend to his 
allotted share of the duties, and all conversation while in the sur- 



TECHNIQUE OF AX ASEPTIC OPERATION. 39 

gery should be discontinued. We have already described the 
preparation of the patient, instruments and dressings. Before 
beginning work, if the chief operator inspects his outfit carefully 
to note if all instruments needed are in place, and a sufficient 
amount, of pledgets and dressings, it may save future interrup- 
tions. When the patient is thoroughly under the influence of the 
anaesthetic the part to be operated is exposed and cleansed, if this 
has not been done before the anaesthetic is given. The patient 
should be well wrapped in dry blankets, and over these clean 
sheets or towels should ^e spread. In the immediate neighbor- 
hood of the operative wound towels wrung out in antiseptic solu- 
tions must be spread, so as to leave only the site of the proposed 
operation exposed. As soon as soiled these towels are replaced 
by clean ones. If the work is to be done about the head or upper 
thorax, a damp towel should be placed about these regions so 
that the patient's hair may not touch the operator's hands or the 
instruments, thus increasing the chances for infection. The 
asepsis present at the beginning must be maintained throughout 
the operation. Quiet working and the avoidance of unseemly 
haste are conducive to this end. If any of the instruments should 
drop on the floor during the work they should be laid aside and 
not used again unless re-sterilized. Dressings that come in con- 
tact with unsterilized articles should be cast away. 

The Incision. — Before the incision is formed the superficial 
tissues to be divided should be made tense at either side by the 
hands of the surgeon and assistant. If this is not done the skin 
will wrinkle as the knife passes and the incision will be irregular. 
Primary incisions should be clean cut from end to end, and should 
be long enough to permit a good view of the parts involved. A 
long, clean-cut incision will heal quicker than a short one that 
limits the boundaries of the operative field, and thus be the means 
of impairing the vitality of the tissues, which will be injured by 
the efforts directed to the accomplishment of a definite idea with- 
in a too limited area. 

Dissections. — After the incisions are made the wound edges 
fall apart and should be separated by retractors held by the as- 
sistants. If the superficial vessels are cut an artery forcep applied 
will stop further bleeding, or pressure by a gauze pledget pressed 



4-0 MINOR SURGERY. 

upon the bleeding point may be all that is necessary to control it. 
The retractors should be handled so as to raise up the parts cut 
through, and thus enable the operator to recognize the different 
structures before they are divided. It is important to make the 
deeper incisions as nearly as possible along the line of the course 
of the vessels, nerves and muscular fibres that may be in the way. 
Before the structures are divided they should be picked up by 
means of two pairs of rat-toothed forceps in the hands of the sur- 
geon and assistant. The surgeon who knows his anatomy will 
find it a good plan, when dissecting in the neighborhood of large 
vessels and nerves, to first expose them and then endeavor to 
work away from this course, and so avoid wounding them. If it 
is necessary to sever the vessel, and it is recognized before the 
division is made, it should be clamped by two forceps and divided 
between them and a ligature passed about each end. If a vessel 
is cut and spurts a forcep and ligature applied will readily control 
the bleeding. If there is hemorrhage without spurting firm 
pressure for a few seconds with a pledget will enable one to see 
the bleeding point, and the vessel can be caught and tied off. 
Enough of the vessel should be caught in the bite of the ligature 
so that the ligature will not slip. Hemorrhage should be con- 
trolled as the dissection progresses. In ligating vessels the fine 
ligature is best so long as it is strong, for the knot is less liable to 
slip. If it becomes necessary to discontinue the operation for a 
time the wound is covered with gauze pledgets. 

As soon as the operation is completed the wound may be irri- 
gated with sterilized water which will float small particles of 
detached tissues and bits of blood clots out of the cavity. The 
wound should be wiped dry with a pledget of gauze. A dry 
pledget firmly applied may check oozing of blood if present; if 
simple pressure does not stop the bleeding irrigation with hot 
water followed by pressure with pieces of gauze wrung out in hot 
water should be tried. If the flow does not stop a gauze pad of 
hot water should be packed into the wound and the sutures 
introduced. Before these are tied the tampon should be carefully 
removed and the bleeding area inspected. It may be necessary 
to pass a ligature of catgut through the tissues containing the 
bleeding point. If the flow does not yield to these measures and 



TECHNIQUE OF AN ASEPTIC OPERATION. 4 1 

it is necessary to stop the hemorrhage without further delay, 
tampons of gauze should be placed firmly into the cavity, their 
free ends overhanging the lower end of the incision. Sutures are 
introduced but not tied tightly. A firm bandage is then applied, 
thus enforcing steady pressure. This dressing may be changed 
in a few hours, though in some instances, as hemorrhage from 
the cerebral sinuses, iodoform gauze packing may be left in for 
several days before removal. 

Drainage. — When the surfaces of the wound can be brought 
together and maintained so as to completely close the wound 
cavity no drainage is necessary. The majority of surgeons are 
draining operative wounds less and less. If the operator decides 
that drainage is essential it may be secured by the introduction 
through the most dependent portions of the flaps of one or more 
rubber drainage tubes that have been perforated irregularly. 
The size of the tube should be in relation to the amount of pros- 
pective discharge. As the granulating process develops the tube 
can be shortened from time to time. L,ong pieces of gauze are 
used for drainage, as are also strands of catgut and horse hair. 

The Sutures. — If the wound does not require to be drained 
it is wiped dry, and is then ready for the introduction of the 
sutures. To have primary union of the tissues much depends 
upon the accurate coaptation of the cut edges. Sutures are in- 
troduced near the free edge of the wound as one's judgment 
dictates. In each instance the location and depth of the wound, 
the degree of tension and the suture material has to be considered 
by the operator before the knots are tied. If the wound is of 
large size deep sutures may have to be taken in addition to the 
superficial ones. Deep sutures tend to prevent tension, and if 
there is any exudation that would force the edges of the wound 
apart they will help to prevent this. 

Where there is apt to be much tension during the healing pro- 
cess additional means of support can be used. Straps of rubber 
adhesive plaster, sterilized by passing the cloth side through the 
flame of an alcohol lamp, applied at right angles to the wound 
act as a splint. Collodion spread over the wound answers the 
same purpose and prevents the admission of air. 

Care must be taken not to draw the sutures too tight, for the 



42 MINOR SURGERY. 

tissues so grasped will be strangulated, and as a result suppura- 
tion of the edges of the wound will occur. After the sutures are 
tied the surgeon with the aid of dressing forceps should examine 
the cut edges and see that they are not turned under, but the raw 
edges are in apposition. 

Dressings. — Any of the dry dressing powders may be sprinkled 
over the wound. A favorite dressing is one composed of equal 
parts of Calendula and Boracic acid. Plenty of sterile gauze and 
cotton should be placed over and about the site of the operation. 
It is false economy to be saving with the dressings. Sterilized 
bandages are then applied. 

After Treatment. — The patient is wiped dry if wet, and 
taken back to bed and placed between blankets that have been 
previously warmed. Hot water bottles wrapped in towels are to 
be placed about the patient, care being taken that the heat is not 
excessive and so burn the patient. If necessary stimulants may 
be given. If symptoms of shock appear energetic measures must 
be taken to combat this condition. The treatment of shock will 
be found in the chapter devoted to the subject. 



CHAPTER VI. 



THE TECHNIQUE OF AN ASEPTIC OPERATION. 

It will be noted that m the preceding chapter no mention was 
made of the use of the antiseptic solutions. Everything used in 
the performance of the operation was considered to be surgically 
clean, and the wound was not irrigated or swabbed with the vari- 
ous antiseptics. 

The details of an antiseptic operation require the liberal use of 
germicidal solutions. The general rules that apply to operative 
procedures should be strictly enforced. The patient, instruments, 
dressings, etc. , are sterilized with the greatest of care, and all the 
details previously described carefully observed. A generous 
supply of bichloride solution in different strengths should be in 
readiness. The fluids ought to be used as hot as can be borne 
with comfort by the hands. Hot solutions help to prevent the 
shock of operation, and also possess germicidal qualities. The 
field of operation is exposed and the surrounding parts protected 
with towels wrung out in hot Bichloride or Boracic acid solutions. 
The skin is then irrigated, and the hands of the operator and as- 
sistant are kept wet with the fluid. The incision is made per 
directions, and hemorrhage controlled as the operation proceeds. 
The different layers of tissue are irrigated with antiseptics as they 
are exposed. The sutures are then introduced, but before tying 
the wound is again irrigated. Before the dressing is applied the 
wound and adjacent skin are given a final irrigation. If no 
drainage is to be used a dressing powder is dusted over the 
wound and a dressing of moist Bichloride gauze applied. Over 
this damp gauze several thicknesses of dry gauze are spread, over- 
lapping the first layer. Plenty of Bichloride cotton is then 
added, covering in the whole. The dressing is held in place by 
bandages fitted to the part. 



44 MINOR SURGKRY. 

Drainagk. — If drainage is demanded, perforated rubber tubes 
or strips of gauze, either iodoform or bichloride, are introduced into 
the cavity as required. The tube is useful, in that the irrigating 
fluid can reach the bottom of the cavity. When the wound is 
drained the dressings are liberally applied, the wound discharges 
being caught in the meshes of the gauze. 



CHAPTER VII. 



ASEPTIC OPERATION IN A DWELLING ROOM. 

The surgeon may make it an absolute rule to operate only 
when he has at his disposal the means essential to asepsis. This 
resolution is easily broken, however, in exceptional cases. In 
emergencies it is not always practicable to have everything that 
may come in contact with the wound sterilized, though the 
ingenious surgeon who is familiar with the laws of asepsis will 
improvise. Given a fire, oven, water and a clean kettle, liga- 
tures, sutures, instruments and dressings can be asepticized. It 
is under unfavorable conditions demanding operations that the 
rules of asepsis should be strictly heeded. In hospitals suitable 
operating rooms with all the modern paraphernalia are provided. 

We have described in a previous chapter the condition that 
should lead to the selection of a room for operation in a private 
home and its preparation. An improvised operating table is 
made by using the ordinary wooden kitchen table. A second 
table may also be placed at either end of the first table, the 
steadier of the two supporting the heavier part of the body. The 
table may be first scrubbed with soap and water and then covered 
with folded blankets or quilts that have been baked in an oven. 
Over this should be placed a rubber cloth that can be sterilized 
by washing in strong bichloride solution. A clean linen sheet 
that has been baked should be well spread over all. The rubber 
cloth placed beneath the patient can be folded and raised at the 
sides by thin pieces of wood so as to limit the spread of fluids to 
the part of the patient immediately beneath the field of operation, 
or the table may be slightly tilted. A Kelly surgical cushion is 
the best means of conducting discharged fluids into a bucket or 
pan. A patient should be kept as dry as possible, for all unnec- 
essary wetting increases the chances of shock and pneumonia. 



4 6 



MINOR SURGERY. 



If the operation be one of little importance a lounge covered 
with a clean sheet may be used, though all aseptic details should 
be observed as though for the most serious work. A smaller 
table covered with sterilized sheets or towels is necessary to hold 
instruments. A few wooden chairs, their seats covered with 
towels, are required to hold basins or wine bottles that contain 
solutions for cleansing the hands and instruments and to hold 
sponges and gauze pledgets. The operating table should be 



Fig. 4. Improvised apparatus for the irrigation of a wound. 



placed in such a position that the direct rays of light will fall 
directly on the field of operation. The table for instruments and 
chairs with supplies should be drawn near to those who will make 
use of them. 

Instruments and Dressings. — The instruments and the 
dressings should be laid out in an orderly manner so that no con- 
fusion will ensue when they are hurriedly required for use. 



ASEPTIC OPERATION IN DWELLING ROOM. 47 

China platters and bowls that have been boiled are needed to hold 
instruments. Hemostatic forceps should be kept in a bowl apart. 
Clean soup plates may be used to hold ligatures, sutures, and 
other needed materials. It will save time and confusion to have 
needles threaded with the sutures, and ligatures cut, and both 
laid out in such a way that knots and snarls will not form. In- 
struments should be covered with clean towels after they have 
been sterilized until they are needed. A simple way to sterilize 
instruments is to boil in water for twenty minutes. A table- 
spoonful of soda added to the water increases the cleansing effect. 

Dressings are required in liberal quantities. It is a mistake to 
attempt to be economical in the matter of dressings. Several 
yards of sterilized prepared gauze must be supplied, as also should 
plenty of absorbent cotton. Pledgets of gauze and small rolled 
balls of cotton are used for sponging. Old cotton or linen, boiled 
and ironed with a very hot iron, may be used for sponges and also 
as a dressing. Old clean sheets may be prepared and used in the 
same way. There should be plenty of roller bandages, pins, and 
a few dozen towels. Some surgeons sterilize their dressings at 
home or hospital, and then carry them in air-tight metal cans. 
Portable sterilizers are made and are useful where one operates 
considerably away from a hospital. In an emergency an ordinary 
clothes-boiler may be used. The platters, bowls, plates, pitchers, 
basins, after being washed with soap and water, rinsed, may be 
laid in a large towel or sheet and put in the boiler with plenty of 
water and boiled for fifteen minutes. The ends of the sheet or 
towel are allowed to overhang the edge of the boiler, so that the 
articles may be removed by grasping these ends and lifting the 
utensils from the hot water. The dishes may then be set in their 
places, the materials placed in order and covered with clean 
towels. 

The Operator and Assistants. — In emergencies the hands 
and forearms can be scrubbed with soap and water, to which may 
be added a teaspoonful of ammonia. Where there is time the 
prescribed methods of sterilization should be used. Plenty of as- 
sistants are necessary, even if unskilled. Improvised operating 
gowns have already been described. Clean night-shirts may be 
also used in place of operating gowns. 



48 MINOR SURGKRY. 

Thk Patient. — The patient should be prepared with as much 
care as if working in a marble-lined operating pavilion. If there 
is time all details should be observed and religiously carried out, 
as has been before described. 



CHAPTER VIII. 



THE REDRESSING OF WOUNDS AND DRAINAGE. 

WOIJND INFECTION. 

The redressing of wounds in accordance with the laws of asep- 
sis requires that all the details already mentioned be scrupulously 
observed. The hands, instruments and dressing materials are 
sterilized in the proper manner. A wound which is aseptic heals 
without symptoms provided the part is kept at rest. Of course if 
there is tension on the coapted parts or sutures the condition of 
rest is really not procurable. If all aseptic precautions have been 
observed during the operation, and the wound appeared healthy, 
it is safe to say that the dressings may be left undisturbed for a 
week or ten days. 

It is surprising how small a degree of pain will often result 
from very large aseptic wounds. If the pain increases, however, 
or there is chill and fever, change of dressing is necessary. If 
there is pain alone it may be due to the tension and may last sev- 
eral days. A slight elevation of temperature may also be due to 
tension on the parts, though the tissues often become gradually 
accustomed to being stretched and the symptoms disappear. 
Tightly drawn sutures may cause a necrotic condition that would 
necessitate a frequent change of dressings. 

The cutaneous edges of an aseptic wound adhere strongly 
enough to allow the removal of the sutures in from four to five 
days, but for at least ten days it is necessary to prevent unusual 
tension which may reopen the wound. The deeper tissues as 
fascia, tendon and bone require longer time to heal, three to six 
weeks being necessary, provided there is local rest given to the 
parts involved. Of course recurrent or secondary hemorrhage 
indicates a speedy change of dressings and the bleeding con- 
trolled. If drainage has been used and the dressings are satur- 
4 



50 MINOR SURGERY. 

ated by the discharges from the wound a change is necessary. 
The discharge is generally very scanty in aseptic healing, being 
limited to a slight exudation of serum during the process of 
agglutinization. In redressing a wound made under aseptic pre- 
cautions it must be borne in mind that antiseptic agents are not 
to be used, sterilized gauze and cotton replacing the original 
dressings. It is important that irrigating fluids should not be 
forced down between the sides of the wound wall unless suppura- 
tion has actually occurred. The fluid separates the tissues and 
retards healing. In the removal of gauze dressings it is a good 
plan to carefully ease the dressing on either side of the wound 
before its removal directly over the line of incision. Otherwise 
too strong efforts on one side may be the cause of the separation 
of the wound edges. 




Fig. 5. Drainage tubes, (a) Glass. {b) Rubber. 

In operative wounds where the antiseptic method has been 
used the dressing need not be changed until symptoms arise de- 
manding it. Pain in wounds is often due to the dressings becom- 
ing adherent to the cut surfaces, and when dry cause pressure and 
pain. When relieved the pain will disappear, if there are no other 
causes. Solutions of Hydrogen peroxide are very useful to facil- 
itate the removal of dried gauze; hot water is also used. Under 
the antiseptic method the wound surface when exposed, as well 
as the skin, is washed off with Bichloride solution 1:2000. The 
superficial and deep portions of the wound are then irrigated with 
the same agent, and the drainage tube removed if the wound is 
aseptic; if not, the tube may be sterilized and replaced, being 
made shorter or a smaller one introduced if the wound is closing 
up and further drainage is necessary. The surface of the wound 
is again irrigated and antiseptic dressings applied. The subse- 
quent wound dressings depend on the condition and symptoms. 



REDRESSING OF WOUNDS AND DRAINAGE. 5 1 

It is a mistake to dress a wound too often, or even inspect it. 
Peroxide of Hydrogen is the best agent for cleansing the deeper 
portions of a cavity if pus is present. There is no doubt that 
wounds are dressed too often and wiped too freely. There may 
be a strong temptation to wipe away the pus from a granulating 
wound when it is suppurating freely with a sponge or pledget; 
yet in most wounds we will do the best for our patient by not 
meddling with the reparative process. Granulation tissue suffers 
traumatism whenever it is touched, and as a result there will 
develop exuberant granulation tissue with a poor blood supply. 
The thin epithelium that grows across the wound is extremely 
delicate and the slightest touch will damage it. If gauze is re- 
moved directly from its surface at short intervals some of the hy- 
aline epithelium is sure to be removed and so retard the healing 
of the wound. If the patient or family complain because the 
wound is being apparently neglected, an explanation will ease 
their minds. 

Wound Infection. — If the proper technique is not observed 
while doing dressings it is very easy to infect the wound partially 
or in general. Evidence of slight infection may be small hyper- 
aemic spots away from the cut surfaces about the stitches. This 
may be the beginning of a so-called "stitch abscess." These 
stitches should be removed as the suture material is very probably 
imperfect. A drop or two of pus may be found, and this should 
be wiped out or washed out. Compresses soaked in pure alcohol 
will often prevent further cutaneous inflammation . There -is 
usually a slight but steady elevation of temperature with stitch 
abscess, though few, if any, constitutional symptoms. General 
wound infection will be treated of in a special chapter. 

Drainage of Wounds. — The question of the advisability of 
drainage is a very important one. Surgeons who are sure of their 
technique are using drainage in operative wounds far less fre- 
quently than formerly; especially is this true of abdominal opera- 
tions. It is a matter which depends largely on the location and 
type of the wound. The subject of drainage of wounds may be 
divided into two classes: (a), the drainage of wounds which are 
surgically clean, or are supposed to be such; (b), the drainage of 
wounds which are made to relieve suppurative or septic condi- 
tions. 



52 MINOR SURGERY. 

Drainage should be limited among the clean cases to the follow- 
ing varieties: i. In those cases where there has been much trau- 
matism to the tissues, and where large areas of lymphatic vessels 
have been opened oozing may be expected, and it seems desirable 
to prevent the collection of such fluid in some dependent part of 
the wound. 2. Where there remain at the termination of the 
operation so-called dead spaces which cannot be obliterated by 
deep sutures or other means. These are apt to act as receptacles 
for any serum or lymph which may escape from the lacerated 
vessels, and which might then furnish a culture medium for some 
of the bacteria which may be found in almost any aseptic wound. 
Twenty- four hours is sufficiently long in almost all cases for the 
drain to be left in the wound. 

In the second class, namely, infected wounds and those made 
to relieve, a septic focus drainage is demanded almost without ex- 
ception. Drainage of abscesses, empyemas, suppurating joints, 
etc., is effected in the location which gives the best possible 
escape to the secretions. 

A healing cavity must not be drained for too long a time. 
The drain may act as a seton actually keeping up the suppura- 
tion. In draining spaces whose walls are flaccid and tend to fall 
together gauze does very well. When there is a true cavity, 
however, a tube will usually be more efficient. We have found 
it a safe plan to provide at least some drainage to nearly all 
wounds the result of accidents. 



CHAPTER IX 



HEMORRHAGE— BLEEDING. 

There is no condition so appalling as hemorrhage, and there 
probably is none which calls for such quick action to combat it. 
To successfully treat bleeding a thorough knowledge of the meas- 
ures employed and their application is essential. 

Hemorrhage may be either arterial, venous or capillary, or we 
may have a combination of the three. When an artery has been 
cut the blood is scarlet in color, and spurts with the pulse beats. 

Venous hemorrhage is denoted by the dark color of the blood 
and by the continuous stream. In capillary hemorrhage red 
blood oozes up but does not spurt. 

Profuse hemorrhage induces constitutional symptoms, and 
death may occur in a few seconds, depending on the size of the 
vessel injured. After losing much blood a person is very pale 
and of a greenish hue, the eyes are fixed and glassy with dilated 
pupils, the respirations are shallow, the skin is cold, clammy and 
covered with a cold sweat, the limbs are cold, the pulse is weak, 
irregular and often not felt, and the heart is weak and fluttering. 

Generally after the bleeding has gone on for a time fainting 
occurs. There may be nausea and vomiting, vertigo, black 
specks float before the eyes, and there is a ringing in the ears. 
It is obvious that a condition inducing such a serious train of 
symptoms can best be treated by the removal of the cause. 

Temporary measures are to be quickly adopted until the bleed- 
ing vessels are caught and tied. The constitutional symptoms 
are to be relieved by stimulants, heat, electricity, and after the 
flow has been checked the normal salt solution should be injected 
into the veins. The use of this extremely valuable agent is fully 
described in another chapter. 

Hypodermic injections of brandy, Strychnia in doses of 2V 
grain, Atropine, Digitalis, Morphine and Nitroglycerine and 
Ergotine are recommended. 



54 



MINOR SURGERY. 



Enemata of hot coffee and whisky should be given, and mus- 
tard applied over the heart and spine. 

The patient should be kept quiet with the head lowered, com- 
pression being made upon the femoral and subclavian arteries so 
as to divert more blood to the brain. 




Fig. 6. Digital compression of the brachial artery. 

The lower extremities may be bandaged with the same idea in 
view. The diet should be light but nourishing, including soup, 
egg-nog, peptonoids, broths, milk, etc. 

We may divide our measures for the control of hemorrhage 
into Temporary and Permanent. 

(i.) Temporary Measures. — A useful and natural hemo- 




Fig. 7. Digital compression of the femoral artery. 



HEMORRHAGE — BLEEDING. 55 

static is digital compression, which, as its name suggests, is made ef- 
fective by the application of force over the bleeding point, or over 
the vessel at the most superficial place of its course. The fingers 
and thumb supply the necessary amount of force, though, for 
superficial vessels, often light pressure only is required. For the 
deeper arteries and veins it should be the aim to make pressure 
over the vessels, with bony structures for counter pressure. 
When the deeper structures are injured this method of controlling 
the hemorrhage is tiresome if kept up for a few hours, and may 
injure the vitality of the tissues. 

The surgeon may apply the necessary amount of force to con- 
trol the hemorrhage by pressing his thumb over and into the 
spot. 

When this member is tired the fingers can be used successively 
for the same purpose. The possibility of concealed hemorrhage in 
such instances is of enough importance to make efforts to avoid 
it, and the artery or vein should be tied off early. 




Digital compression of brachial artery. 



Tourniquets. — An improvised tourniquet that is often of valu- 
able service in street, railroad and shop accidents is made by ty- 
ing a strong handkerchief about the part above the injury and 
tightly twisting with any kind of stick. If there is time a second 
handkerchief, folded into a pad and placed over the course of the 
artery before the first one is tightened, will help to secure more 
direct pressure, and also tend to prevent such after- results as 
paralysis, sloughing and pain, which are not infrequently caused. 

If the agent is applied too long gangrene of the part is the 
usual result. Esmark's Tourniquet is a piece of ^ inch rubber 



56 MINOR SURGERY. 

tubing about two feet long, with a hook at each end. Bsmark's 
rubber bandage does equally as well. This is also used previous 
to operations on limbs, to make these parts bloodless and so pre- 
vent hemorrhage. 




Fig. 9. I 



mprovised tourniquet for compressing an artery with 
a handkerchief and a stick. 



Pettifs Tourniquet, which consists of a canvas strap with a 
thumb-screw that makes counter pressure after the strap is ap- 
plied about a limb, is an effective instrument. 

Forced Flexion. — In some instances pressure can be made by 
immobilizing a forcibly flexed joint. A pad of gauze placed in the 
apex firmly aids the purpose. A rubber or cotton bandage is 
then used to immobolize the parts until more effective measures 
can be taken. 

(2. ) Permanent Measures. — Ligation. — Well prepared chro- 
matized catgut is the ideal ligature. Plain catgut silk, kangaroo 
tendon are used, but experience seems to favor chromatized cat- 
gut. 

This is true even when used for large arteries. Ligatures 
should be about twelve inches long, the size depending on the 
caliber of the vessel to be tied. 

The vessel is drawn out with forceps and separated from sur- 
rounding tissues. The traction should be made steadily over the 
ends of the forefingers or thumb, and the ends not jerked. 

If an artery is completely divided, tie on each side of the cut 
and sever the vessel between the ligatures. Tie with the sur- 
geon's knot. The tightening of the first knot cuts the internal 
coats, the second knot must not be tied too tightly or it will cut 
the ligature. The firm opposition of the surfaces of the inner 
coat is adequate for the establishment of a clot. Great caution 
ought to be exercised to prevent a nerve from being tied in, for 
the pain of such accident is severe. 



HEMORRHAGE — BLEEDING. 



57 




Fig. io. Diagram showing the action of the ligature. 

Some surgeons apply a double ligature, their idea being to 
avoid secondary hemorrhage should the first constriction slip or 
otherwise give away. In emergencies strong cotton thread can 
be boiled and used for ligaturing. 




^m 



Fig. ii. Clots formed after division of an artery. 
(a and b) Outer and inner coats, (c and d) Internal clot. (<?) External clot. 



HEMORRHAGE. 

Torsion. — Consists in isolating and drawing down the end of 
the vessel, seizing it firmly with a forceps about one-half inch 
above its extremity, and twisting the end several times with an- 
other pair of forceps till the blood pressure is overcome, care 
being taken not to twist it off. The twisting process mutilates 
and breaks up the coats of the vessel and so closes the caliber 
and causes a rapid formation of the internal clot. 

Torsion is not considered a good substitute for ligaturing ex- 
cept to close the small bleeding points seen on the surface of 
fresh wounds, and for such purposes only one forceps is needed. 



58 



MINOR SURGERY. 



The end of the vessel should be seized and twisted and the other 
tissues avoided. 

Forcipressure. — Hemostatic forceps are of the greatest utility 
in the control of bleeding points during an operation. Forceps 
are quickly and easily adjusted, and hemorrhage absolutely con- 
trolled if a vessel be the source of the bleeding. Forceps by the 
continued pressure on the walls of the small vessels often obviates 
the necessity of applying ligatures. Forceps can be left in place 




Fig. 12. Method of controlling hemorrhage by torsion. 



until the operation is finished and may then be released after the 
point has been secured by ligature, or the bleeding points may be 
caught and tied off as the vessels are cut. A ligature can be 
loosely tied about the jaws of the forceps and then slipped down 
upon the tissue to be tied off, tightened and the forceps removed. 
In using hemostatic forceps great care should be employed not to 
include any tissues excepting the vessel itself. Local necrosis is 
of ten 'caused by the too prolonged application to too much tissue, 
and has led to suppuration in wounds that would have healed 
aseptically. 

Forceps are made in different sizes and styles, and can be pro- 
cured for almost any condition as required. They are strong and 
serviceable, and before being boiled should be unlocked and taken 
apart. 

Pressure. — In some instances the application of a ligature is 



HEMORRHAGE — BLEEDING. 



59 



not advisable even though the artery be secured by forceps. 
This applies to the larger arteries, such as are cut in some gyneco- 
logical operations. For such cases hemostatic forceps of con- 
siderable size and strength are locked onto the bleeding vessel 
and allowed to remain from twenty-four to forty-eight hours. A 
ligature is then applied and the forceps removed. 




Fig. 13. Curved Hemostatic forceps. 




4. Straight Hemostatic forceps. 



In hemorrhage or general oozing following operations in such 
cavities as the rectum, vagina, nose, cranial sinuses, medullary 
canal or the socket of a tooth, it is often necessary to pack strands 
of bichloride, iodoform or plain gauze into the cavity. This is 
left for twenty-four or forty-eight hours and then carefully 
removed, and may be reapplied if indicated. 



60 MINOR SURGERY. 

In scalp wounds where the hemorrhage is often greatly due to 
the great vascularit} T of the parts, pressure is effected by coapta- 
tion of the edges of the wound by sutures. 

Aseptic wax is also used for similar purposes. 

Heat. — Hot water at a temperature of 120 F. is an excellent 
agent for arresting bleeding. At this temperature it is also an 
antiseptic and stimulant. Hot water may be applied by irriga- 
tion or by pledgets or towels wrung out and packed into the 
wound. This agent is especially valuable where there is general 
oozing in a large cavity and vessels of small calibre are injured. 

The actual cauter} T is an effective hemostatic and checks the 
bleeding either by forming aseptic escher at the end of the vessel 
or causing the end to curl up and invert, thus finally closing the 
vessel. The Paquelin cauter} T is the best, and should be used at 
a dull red heat and applied for a few moments to the bleeding 
point. The galvano-cautery or an ordinary cautery iron answers 
the same purpose, so does a stove poker which might be used at 
a bright red or white heat is hemostatic in action. 




Fig. 15. Arrest of hemorrhage by passing a suture ligature. 

Deep suturing, known as ligation en masse, consists in passing 
a ligature through the tissues around a vessel by means of a 
needle whose points of entrance and exit are near to each other. 
This method is indicated in cases where the end of the vessel can- 
not be caught up, as occurs in certain wounds or in dense tissues. 

Styptics. — Certain chemical agents will arrest hemorrhage by 
causing coagulation of the blood. The agents are not so univer- 
sal^ used at the present time as formerly, because of the unsatis- 
factory results following their introduction into a wound. While 
often effective in the purpose for which used the agents may dis- 
guise the presence of foreign bodies, render cleansing imperfect, 



HEMORRHAGE — BLEEDING. 6 1 

and often prevent primary union. Hot water is the most satis- 
factory styptic, and used at n8° F. is aseptic. 

Park's mixture, consisting of Antipyrine and Tannin solution, 
each of 15 per cent, strength, mixed, is an aseptic styptic and 
should be more favored in the choice of a styptic. 

Solutions of Subsulphate and Persulphate of Iron, Alum, Tan- 
nin and Resin are among the common agents used. A mixture 
of Chloroform one part and water fifty parts will rapidly arrest 
hemorrhage after tooth extraction. 

Styptic collodion applied to the united lips of a wound with a 
camel's hair pencil not only controls the oozing, but aids primary 
union by causing closer coaptation of the wound borders and the 
exclusion of external infection. 

Acupressure. — This was formerly a much used method for 
controlling bleeding. It is applied in two ways, one where the 
pin is carried through the soft parts under the vessel and the 
point elevated and. pushed through at an angle sufficient to cause 
it to tightly close the lumen of the artery by pressing the vessel 
against the overlying tissues; several turns of a silk ligature are 
then passed beneath each extremity and obliquely above the pin. 
The second method is the reverse of the first, the pin resting upon 
and pressing the vessel downward upon the deep-seated tissue in- 
stead of upward against the superficial. Acupressure may be 
employed to control hemorrhage from small arteries of the hand 
or foot and superficial vessels. 

Position. — That the position of a part has an effect upon the 
bleeding is shown especially in hemorrhage from the limbs. If 
the part is raised above the level of the body generally oozing 
will soon cease. This is noticeable in amputation wounds. Cold 
water and ice water can be used successfully to combat hemor- 
rhage. Cold water at one time was a favorite agent to control 
bleeding, but now hot water is used instead. 



THE ANGIOTRIBE. 

What is better than arresting hemorrhage is to prevent its 
occurrence. The angiotribe in many instances will accomplish 
this desirable end. This instrument is a powerful heavy forceps 



62 



MINOR SURGERY. 
LIGATIONS. 



Plate i. 




i. Opening the Sheath for Ligation of an Artery (Guerin). 2. Sheath of Artery Open (Guerin). 
3. Tightening the Knot in Ligation (Guerin). 4. Anatomy of the Iliac Arteries, and showing the 
lines of incision for their ligation : 1, Abernethy's incision (Guerin). 5, 6. Ballance and Ed- 
mund's Stay-knots. 



HEMORRHAGE — BLEEDING. 63 

capable of exerting 3,000 pounds pressure when applied to the 
tissues and clamped. It is a useful instrument and has been 
introduced to supplement the ligature. Unfortunately its use is 
limited to some gynecological and rectal operations. The jaws of 
the instrument are clamped at right angles to the blood vessels, 
and for three minutes the maximum pressure, 3,000 pounds, is 
maintained. This heavy pressure crushes but does not cut 
through the walls of the vessels, and nature's method of arrest- 
ing hemorrhage by contraction, retraction and clotting is imitated. 
The blood vessel outside of the clamp may then be divided, and 
there is little or no danger of hemorrhage. 

Some surgeons use the angiotribe to crush the tissues and form 
a groove in which a catgut ligature can remain without danger of 
its slipping. 

With the angiotribe there is no puckering or traction, and a 
case of tissue necrosis has never been reported. Post-operative 
shock is diminished, and the intensity and duration of the post- 
operative pain is lessened and convalescence is quicker. 

GELATINE AS A HEMOSTATIC. 

Gelatine has been proven to be of service as a hemostatic 
applied locally or injected hypodermically. The gelatine must 
be carefully sterilized, which is best accomplished by heating it to 
a ioo° C. on two successive days. The flask can then be plugged, 
and on steeping it in warm water its contents become fluid and 
are ready for use. 

For local applications a 5 to 10 per cent, solution in 0.7 per 
cent, salt solution is effective in metrorrhagia, bleeding from 
piles and from the lower bowel, epistaxis, bleeding from gastric 
ulcer, vesical hemorrhage and oozing from wounds and open sur- 
faces. Its action is rapid and lasting and without danger. The 
subcutaneous injection of gelatine can be used to treat cases of 
hemoptysis, hemophilic bleedings, bleeding from toxemia and 
hemorrhages occurring in typhoid fever. A 2 per cent, solution 
is used, and, as a rule, about six ounces is injected daily for sev- 
eral days in succession. 

In obstinate hemorrhage after operations it is effective, and also 



6 4 



MINOR SURGERY. 



in purpura hemorrhagica. Several cases of aneurism have been 
reported cured by injection of gelatine. Gelatine acts by increas- 
ing the coagulability of healthy and pathological blood. It is 
harmless if antiseptic precautions are carefully carried out, though 
heart and kidney disease contradict its use. 

MORPHINE AS A HEMOSTATIC. 

Morphine used hypodermically in the treatment of active 
hemorrhage often stops the bleeding miraculously. While there 
is internal and severe hemorrhage, such as occur in typhoid fever 
and from the lungs and stomach, an injection of an eighth or one- 
quarter grain of morphine will save life by controlling the blood 
loss. 




Fig. 16. Method of controlling hemorrhage by ligature. 
(a) Artery ligated. (b) Lateral ligature of vein. 

SUTURES OF VEINS AND ARTERIES. 

Wounds of the larger veins have been successfully treated by 
suture, and this has been a recognized method of treatment since 
the eighties. 

The hemorrhage should be stopped by pressure made upon the 
vessel upon both sides of the vessel, and the wound in the vein 
should be closed by fine silk sutures applied closely together by 
means of a very fine needle. Small wounds of large veins may 



HEMORRHAGE — BLEEDING. 65 

be well treated by the use of the lateral ligature. In this pro- 
cedure the wall of the vein is pinched and includes the orifice of 
the wound. A fine silk ligature is tied about it. 

These methods of treatment successfully carried out are effect- 
ive in controlling the hemorrhage and still preserve the vessel. 





Fig. 17. Application of lateral ligature to a vein. 

SUTURE OF ARTERIES. 

The suture of arteries was generally considered impracticable 
until Jassinowsky's experiments showed, in 1889, that even gap- 
ing wounds, if not too large, could be closed by suture without 
subsequent occlusion of the arterial lumen. Since then a number 
of experiments on animals have been made, and the principles of 
lateral suture have been carried out in man sixteen times, often 
with complete success, the arteries involved being the carotid, 
femoral, external iliac, axillary and brachial. The technique of 
the operation is not yet exactly settled. Silk sutures are prob- 
ably better than catgut, because they can be procured finer and 
can be knotted more easily. Jassinowsky recommends that the 
sutures should not include the intima, because, if they do, the 
opposite wall of the vessel may be included also, and secondary 
hemorrhage is more probable. Doerfler, on the other hand, 
would include the intima, because the operation (1), is easier and 
more rapidly performed; (2), can be carried out on thin- walled 
arteries; and (3), removes the danger, inherent to the other 
method, of suturing too superficially, and so inviting secondary 
hemorrhage. 

It has been shown experimentally that if sutures which include 
the intima cut their way out, they always do so externally, and 
5 



66 MINOR SURGKRY. 

do not cause thrombosis. It is uncertain whether interrupted or 
continuous sutures are preferable. The slight bleeding from the 
needle tracks can be stopped by pressure, though it is well to 
suture the adventitia over them and the sheath of the vessel over 
all. If this is not possible the vessel should be covered with a 
flap of neighboring connective tissue or muscle. In this way lon- 
gitudinal wounds of arteries of almost any length, certainly up to 
y± inch, can be closed successfully. According to Murphy and 
Doerfler the suture of oblique or semi-lunar wounds is not justifi- 
able if they involve more than half the circumference of the 
artery. For such wounds and for complete transverse division of 
arteries Murphy's method is applicable. This consists in invag- 
inating the central end of the divided artery into the lumen of the 
peripheral portion, which, if necessary, is enlarged by slitting it 
longitudinally for a short distance. The central end is first pro- 
vided with three sutures which involve the adventitia and media 
alone; these are then passed through the peripheral end from with- 
in outwards and tied. In this way a considerable surface of the two 
ends is approximated. The margin of the invaginans, or peri- 
pheral end, is finally fixed to the adventitia and media of the in- 
vaginatum, or central end, and the sheath of the vessel is sutured 
over all. Murphy has successfully joined the femoral artery in 
this way, after resecting y 2 inch of the vessel together with a 
traumatic aneurism; the invaginated portion was y> inch long. 
Kummell resected two inches of the femoral artery, which was in- 
volved in a malignant growth, and joined the two ends by invag- 
ination. After healing, the elastica interna is absent under the 
cicatrix, but the endothelium is restored. 



CHAPTER X. 



SHOCK OR COLLAPSE. 

This is a condition the real nature of which is not perfectly 
understood, but for ordinary purposes it may be stated that shock 
is the prostration of the vital functions caused by any traumatism 
or mental disturbance. 

The symptoms of shock vary. In a slight case there is a feel- 
ing of weakness in the pericardial region and pallor. In more 
severe cases the skin is cold and clammy and covered with beads 
of cold perspiration, the extremities are cold r the face pinched, 
the lips of a bluish hue, the eyes dull, and the pupils dilated, 
the pulse is rapid and irregular, the respiration weak, and the 
temperature subnormal. 

In the treatment of shock the use of heat and the normal salt 
solution is of the greatest importance. The salt solution is best 
injected intra- venously, though the fluid may be forced into the 
rectum or into the cellular tissues. Heart stimulants include 
one-sixtieth grain Strychnia, one-hundredth grain Nitroglycerine, 
fifteen drops aromatic spirits of Ammonia, and one-one-hundred- 
and-fiftieth grain Atropine. These drugs should be given hypo- 
dermically, the dose repeated as the condition requires. Inhala- 
tions of oxygen are beneficial. The patient should be placed 
between warm blankets and hot-water bottles applied to the ex- 
tremities and trunk. Friction of the body is an aid. 

Veratrum album and Camphor are indicated. The injection of 
the salt solution is described elsewhere in this volume. 



CHAPTER XI 



GENERAL SURGICAL ANAESTHESIA AND 
ANAESTHETICS. 

Anaesthesia is a condition of insensibility or loss of feeling 
artificially produced. An anaesthetic is an agent which produces 
insensibility or loss of feeling. An anaesthetist or anaesthetizer 
is the person who administers the anaesthetic. General anaesthe- 
sia is required to prevent pain in surgical operations and labor. 
To produce muscular relaxation in fractures, dislocations and 
herniae, and for diagnostic purposes. 

In 1846 Dr. Morton, of Boston, discovered the anaesthetic prop- 
erties of Sulphuric Ether. A year later Dr. Simpson, of Edin- 
burgh, announced the same properties for Chloroform. Since 
that time these two agents have been rivals in that advantages 
and disadvantages are claimed for each. However, time and 
experience have done much to form certain rules, the observance 
of which help to govern the selection of either drug or their 
modifications. At the present time there is no anaesthetic that 
can be used without some possible risk, though the proper admin- 
istration by a person thoroughly competent will reduce the danger 
to a minimum. 

The anaesthetics in regular use are Ether, Chloroform, A. C. E. 
mixture and Nitrous oxide or laughing gas. Each agent should 
be selected because of its adaptability to the patient to be ex- 
amined or operated. Often the condition of the patient and the 
character and length of the operation will determine the selection 
of the anaesthetic. The fact that drugs capable of depriving a 
person of consciousness to the degree of rendering him insensible 
can not be absolutely free from danger, naturally would make the 
surgeon observe all known practical details. 

The preparation of a patient for anaesthesia is of much import- 
ance. 1. Give the patient a thorough physical examination and 



SURGICAL ANESTHESIA AND ANESTHETICS. 69 

so determine as to the condition of the important organs, and if 
disease be found inform the patient or relatives of the additional 
danger incurred from the use of an anaesthetic. 

2. Enquire as to the length of time elapsed since the last meal, 
when solid food was taken. From six to eight hours should 
intervene between the taking of solid food and the anaesthetic. 
If the stomach is not empty a stomach tube may be used to 
evacuate it, or the operation postponed. If the operation be in 
the morning some liquid food may be given a few hours pre- 
viously. Rectal enema also may be given. 

3. Remove false teeth and plates if present, and other foreign 
bodies. 

4. Loosen the clothing about the neck, chest and abdomen so 
as to prevent even the slightest constriction of the circulation. 

5. Have the bladder and rectum empty. 

6. The patient should lie on his back with the head and 
shoulders slightly raised by a small pillow so as to be in a line 
with the body. 

7. Do not expose the patients to draughts of air. 

8. The anaesthetist should endeavor just before beginning the 
administration of the anaesthetic to gain the confidence of the 
patient. A few words describing the sensations to be experienced 
and the assurance that every care will be taken will often allay 
the apprehensions of imaginary dangers of the nervous or hysteri- 
cal. It is best to anaesthetize a patient in a room free from noise. 

9. The patient should be dressed with a view to the nature of 
the operation so that no unnecessary disturbance will be required 
afterward. The body should be well wrapped up as anaesthetics 
lower temperature. 

10. Do not give an anaesthetic to a woman without the presence 
of a witness. 

1 1 . Do not give an anaesthetic unless absolutely necessary. 

When the patient is ready for operation all unnecessary con- 
versation should cease, because talking often stimulates the 
inebriated fancies causing distorted ideas of what actually occurs. 
The handling of the part and preparation of the site of the opera- 
tion early in the administration disturbs him and delays the drug 
effect and increases the amount necessary for proper anaesthesia. 



70 MINOR SURGKRY. 

The anointment of the face, lips, eyelids with sterilized vaseline 
before the inhaler is applied will prevent irritation. 

The post of anaesthetist is of the greatest importance. In this 
state he is held equally as responsible, legally, with the operator, 
and unless one has a wholesome fear of anaesthetics he cannot be- 
come a safe anaesthetist. The giving of the anaesthetic is a prac- 
tical matter and only learned by personal experience in the oper- 
ating room. So the person chosen for this important duty should 
understand the nature of his work and the treatment of the 
emergencies that so often arise. He should don a sterilized coat, 
wash his hands, and before starting the anaesthetic inspect his kit 
in order to have everything ready for use instantly. The skillful 
anaesthetizer realizes that his share of the work will not enable 
him to watch the details of the operation, and that he must watch 
his patient intently and note carefully the pulse, respiration and 
facies of the patient. At his right side should be a small table 
on which is placed a bottle or can containing the anaesthetic, the 
cone or inhaler, tongue forceps, a mouth gag for separating the 
jaws, clean towels, a small basin to be used if vomiting occurs, 
and two hypodermic syringes filled with a solution of Sulphate of 
Strychnia, the twentieth of a grain, to be used as a stimulant 
should the patient collapse. A small bottle of brandy for hypo- 
dermic use should also be ready for further stimulation. 

Unless specially required narcotizing drugs should not be given 
before anaesthesia. They are an additional danger, as the real 
condition is masked and tend to dry up the natural secretions. 
It is the custom of some surgeons to spray the mucous membrane 
of the nose and pharynx with a solution of cocaine previous to 
the inhalations of either drug to prevent irritation of the sensory 
terminations of the trigeminous distributed to the nasal mucous 
membrane. We feel that this is a doubtful procedure, as the 
cocaine can but be an added danger. A good application is some 
bland oil to which is added a few grains of guaiacol used as a 
spray. This preparation serves the purpose of a cocaine spray, 
and is harmless. 

The administration of the anaesthetic should be begun gradu- 
ally. Tell the patient to close the eyes and breathe regularly. 
It is well to remove the mask after the first whiff and in a second 



SURGICAL ANESTHESIA AND ANESTHETICS. 7 1 

or two replace it. In this way the patient becomes accustomed 
to the fumes and breathes easier. If the amount of anaesthetic 
be increased gradually there will seldom occur disagreeable symp- 
toms such as coughing, vomiting, spasm of the glottis and strug- 
gling. A good way to restrain the struggling patient is for the 
assistants to hold the patient's arms lightly, grasping both wrists 
and pressing them firmly against the table, while the anaesthetist 
should take special care that the head is not raised from the 
table. The operator should not tax his nervous energy to help 
restrain a patient. The reason is apparent. If the patient 
struggles during primary anaesthesia it is usually bad practice to 
force the anaesthetic. In most instances it is a good plan to sus- 
pend the administration and calm the patient. Surgical anaes- 
thesia ought to be complete in ten minutes, and the condition is 
best indicated by a contracted immobile pupil. The habit of 
students and others of pressing on the cornea is only mentioned 
to be condemned. Serious injury of the eye has followed this 
test, and it ought to be stopped. After surgical anaesthesia has 
been attained it should be maintained with the least possible 
amount of the anaesthetic. It is probable that many of the bad 
effects attributed to anaesthetics are due to over-dosing, too rapid 
administration, too faulty preparation of the patient, and too 
careless after-treatment. 

To avoid over-dosage the surgeon ought to commence work 
immediately the patient is ready, and operate as rapidly as circum- 
stances permit. The pupillary reflexes are perhaps the best 
single guide to coming danger; a rapidly dilating pupil indicates 
impending danger, and a fixed dilated pupil means a serious con- 
dition. A contracted, immobile pupil usually indicates safe 
surgical anaesthesia; a pupil alternating between contraction and 
dilation, diminishing anaesthesia. If the anaesthetist will keep his 
finger on one of the arteries of the face or neck the condition of 
the pulse can be constantly observed, and ought to be continu- 
ously. The respiratory function should be closely watched, as 
also should the color of the face, lips, ears and tips of the nose. 
If these parts tend to become of an ashen hue there are good 
prospects of danger. In operations of the rectum where the 
sphincter ani are vigorously stretched the removal of the mask or 



72 MINOR SURGERY. 

ether cone will prevent a too sudden increase in the amount of 
the anaesthetic inhaled, due to the rapid and deep inspirations 
that result from this procedure. The respirations should, as a 
rule, be quiet and unlabored. Loud snoring and snorting indi- 
cates either obstruction or too much of the drug. In the later 
stages embarrassment of respiration may be due to such obstruc- 
tions as the falling back of the tongue or epiglottis, collection of 
mucus in the pharynx or bronchi. 

Vomiting, Coughing or Swallowing. — May occur during 
the later stages. This indicates returning consciousness due to 
an insufficient amount of the anaesthetic, and a prompt increase is 
necessary to prevent the inevitable delay due to this phenomena. 
At the first signs of vomiting or hiccough if pressure is made over 
the course of the phrenic nerve as it passes over the scalenus arti- 
cus muscle, usually on the left side, by placing the thumb just 
above and parallel to the clavicle between the two heads of the 
sterno-cleido mastoid muscle, while the rest of the hand lies upon 
the chest wall, the vomiting may be checked. Pressure should 
be firm but gentle, and should be continued for a time after cessa- 
tion of the phenomena to prevent their return. If the patient 
has been rightly prepared for the operation, and the anaesthetic is 
correctly given, the post-operative vomiting, that is so very an- 
noying, can often be prevented. If it does occur several methods 
of treatment are of service. The patient ought, first of all, to lie 
perfectly quiet. Good results are obtained by giving one-half a 
pint of hot water as soon as the patient is sufficiently conscious to 
swallow. This frees the stomach of accumulated mucus or bile 
by emesis, or carries it into the bowel. Ravage of the stomach is 
also useful, plain water or the normal salt solution introduced 
into the stomach through the stomach tube that is passed as soon 
as the anaesthetic is stopped. A quart of the saline solution in- 
troduced into the colon tends to prevent nausea and the excessive 
thirst. Bits of ice dissolved in the mouth are also of value. In 
some instances inhalations of vinegar will limit nausea; it is used 
by saturating gauze and holding it closely to the nose and mouth 
so its vapor is inhaled. It should be used immediately after the 
anaesthesia is stopped, and should be kept up, if necessary, for a 
few hours. 



SURGICAL ANESTHESIA AND ANESTHETICS. 73 

The patient should be moved about as little as possible during 
and after operation, and when removed to bed he should be placed 
on his right side with his head only slightly raised. Only thin 
liquids in small quantities ought to be given for at least eight 
hours after. Nausea and vomiting following anaesthetics is some- 
times a dangerous condition, and it behooves us to attempt to 
avoid it for the reason that in serious surgical work it may place 
life in peril. 

ACCIDENT^ FROM ANESTHETICS. 

A patient under the effect of such powerful drugs that con- 
sciousness is destroyed is nearer death than an ordinary mortal, 
since the lower vital centers in the medulla oblongata may be 
affected by the same primary depressing influences that first affect 
the high nervous centers. Accidents that are inevitable must be 
watched for and treated promptly and correctly. A few seconds 
of delay at the right time will cost the life of a patient. So here 
again we wish to emphasize the value and importance of the 
skilled and experienced ansesthetizer. 

Arrested respiration is one of the common accidents, and is 
due to depression of the respiratory center by the excessive action 
of the drug, or caused by an accumulation of saliva in the throat, 
or a foreign body in the air passages, and the dropping back of 
the tongue or epiglottis. The appearance of the face is the guide 
for treatment. If the face is flushed or dark red or cyanotic, 
artificial respiration is to be resorted to without delay. If the 
face is very pale this denotes heart failure, and the patient should 
be inverted, besides practicing artificial respiration. Cardiac 
stimulants are also indicated given hypodermically. The most 
valuable drugs that we can employ at such a time are Strychnine 
sulphate ■£$ grain, and Atropine sulphate T -J-g- grain, repeated in 
ten minutes if necessary. Hypodermic injections of brandy, 
Digitalis, Nitroglycerine and Ammonia are also useful. Inhala- 
tions of Ammonia and Nitrite of Amyl are useful. Electricity is 
a valuable aid. Flagellation of the face and chest by towels 
wrung out in cold water and a hot wet towel placed directly over 
the heart are good methods of stimulation. The windows and 



74 MINOR SURGERY. 

doors should be opened to admit fresh air. Stretching the 
sphincter ani seems to exert a good effect, and may be done 
quickly with the fingers or rectal speculum. The reader is 
referred to the special chapter devoted to the methods of artificial 
respiration. 

Accumulations of mucus or foreign bodies obstructing the 
bronchial tubes and larynx require removal. Mucus can be 
wiped out with pledgets of gauze wound around or held by for- 
ceps or probes. If the foreign body is too far down to be reached 
inversion of the patient is to be done quickly, or if this fail and 
the patient is cyanotic, a speedy opening of the trachea is de- 
manded. 

If the tongue falls back breathing is quickly interfered with. In 
most cases this accident may be prevented by keeping the lower 
jaw well forward. This is done by placing the thumbs on the 
symphysis, the fingers behind the angle of the jaw on the ramus, 
and while depressing the symphysis with the thumbs, pulling 
forward with the fingers so as to bring the lower dental arch in 
front of the upper. When this method fails to keep the jaw 
forward a silk ligature may be passed through the tongue and 
fastened outside the mouth, or tongue forceps can be used. 
When the epiglottis drops back it is necessary to introduce the 
finger into the mouth and lift it away from the glottis. 

After stopping the anaesthetic the duty of the person who has 
given it is to watch the patient carefully until he regains con- 
sciousness and intelligence. The face may be wiped off and the 
patient kept in a recumbent position. If there is much shock 
treatment should be instituted at once. (See Chapter on Shock.) 

ANESTHESIA. 

Therapeutics. — Arsenicum album. — Patient has great thirst 
for cold water, which is immediately vomited. Is restless and 
has burning pain in stomach. 

Bryonia alb. — Motion causes nausea and retching. There is 
headache and dryness of the mucous membranes. 

Ipecac. — Nausea and vomiting are constant. 

Nux vomica. — Vomiting with gas in stomach and bowels. 



SURGICAL ANESTHESIA AND ANESTHETICS. 75 

Axomorphia 3X. — Is especially useful for long-continued, per- 
sistent vomiting. 

Veratrum alb. — Much prostration, with cold sweat on face 
and head. The face is pale, and patient complains of sensation 
of weakness. 



CHLOROFORM. 

Chloroform is a colorless liquid having an agreeable odor and a 
rather sweet taste, is of high specific gravity and is somewhat in- 
flammable. The latter property is not generally known, so care 
should be taken that the fumes do not reach a gas or oil flame. 
More fatalities have been reported from the use of chloroform 
than any other anaesthetic, though the high death rate may be 
due partially to lack of knowledge on the part of the anaesthe- 
tizer, many of whom do not realize that dilution of the vapor 
with plenty of fresh air during the time of administration is of 
the very greatest importance. While chloroform may have a few 
more deaths to its credit than ether, it has the advantages of 
being a quicker anaesthetic, and the annoying post-anaesthetic 
conditions are more quickly and quietly recovered from. If the 
student or physician will keep in mind that a combination of 
chloroform and fresh air is imperative to success, accidents will be 
less frequent and the general results will be improved. Chloro- 
form in general is more dangerous than ether, though it is more 
agreeable, less irritant to the lungs and kidneys. The disad- 
vantages of chloroform are that it may induce sudden and fatal 
syncope, as it paralyzes the respiratory and cardiac centres. If 
ether kills it does so through the respiration and not the heart, 
and there is generally time to employ successful means of resus- 
citation. 

Chloroform is to be preferred to ether in the following cases: 

1. For labor cases where moderate anaesthesia only is required. 

2. For operations on the nose, throat and mouth. In such 
cases some surgeons employ ether to put the patient under and 
then give chloroform. 

3. For patients with difficult respiration from any cause. 

4. For patients with kidney disease and diabetes. 



76 MINOR SURGERY. 

5. Operations on the neck where there is, or may be, venous 
engorgement. 

6. In abdominal sections to avoid the common sequelae of ether 
anaesthesia, i. e., vomiting, coughing and struggling, which tend 
to cause tension on the parts, and because it is thought that ether 
causes a venous enlargement and oozing of blood. 

7. In operations about the anus, perineum and genital organs. 

8. For operations that are performed in the presence of a flame 
or stove. Many accidents have been due to the combustion of 
ether vapor, and while chloroform fumes are slightly inflammable 
it is not to such a degree as ether. 

Administration of Chloroform. — For giving chloroform it 
is a good plan to have a two-ounce bottle with glass stopper, a 
notch being in the stopper and neck of the bottle, so that when 
placed opposite each other a drop at a time will escape. Patent 
droppers are not easy to regulate and often allow too much anaes- 
thetic to escape at one time. The Esmark inhaler, which is a 
common wire mask, ought to be sterilized before using, as it may 
readily be infected in operations of septic, diphtheritic and ery- 
sipelatous cases. This mask may be covered with one thickness 
of old linen made from old tablecloths or napkins, or two thick- 
nesses of clean gauze. Fresh coverings should be used each time 
the inhaler is applied. Chloroform can also be given by sprink- 
ling on a folded handkerchief or towel a few drops of the drug 
and placing it over the nose and mouth. A piece of blotting 
paper may also be used. After lightly smearing the lips, nose 
and eyelids with either vaseline, cream or sweet oil, the inhaler is 
placed in position after pouring on two drops. The patient is 
given a whiff to become acquainted with the odor, and then given 
a breath of air. This may be repeated a few times until the 
patient is more familiar with the procedure. The anaesthetist 
may then tell the patient to close his eyes, take slow, steady in- 
spirations and to go to sleep. The drug to get the best results 
should be administered a drop at a time at the rate of two drops 
to the second until the patient is anaesthetized, stopping the drug 
altogether at the first sign of resistance or excitement, and resum- 
ing it again the moment the patient becomes quiet. If the admin- 
istration of the drug is by the drop method the stage of excite- 



SURGICAL ANESTHESIA AND ANESTHETICS. 77 

ment and struggling may be altogether avoided. This is of the 
greatest importance because of the undoubted tendency of the 
drug to produce cardiac paratysis. The time necessary to pro- 
duce anaesthesia varies in different individuals, as also does the 
amount of drug consumed. When the patient is once under the 
influence of chloroform the drug should be administered in small 
quantities, and the patient kept just within the boundaries of 
surgical anaesthesia. 

Cyanosis and stertorous breathing are bad signs, and if these 
symptoms persist it is advisable to substitute ether for the chloro- 
form. The anaesthetist must be constantly anticipating accidents, 
and should both watch the respiratory movements and listen for 
respiratory sounds as well. If sudden heart failure occurs at the 
beginning of the administration of the drug it is caused by true 
actual cardiac paralysis. We have previously mentioned the 
accidents liable to occur. Each assistant should familiarize him- 
self with the treatment of such emergencies and act promptly. 

ETHER. 

Sulphuric Ether is undoubtedly the favorite anaesthetic used in 
this country. A general idea prevails that this drug is safer than 
chloroform, though it is probable that this agent is selected often 
without proper consideration of the case. Ether is contraindi- 
cated in the aged, if marked atheromatous changes are noticeable, 
chronic kidney, bronchial and pulmonary disease, or any intra- 
thoracic affection attended with dyspnoea or cyanosis. Fleshy 
and plethoric persons do not 'stand the effects of ether as well as 
those of relaxed fiber. The chief objections to the use of ether 
are its pungency and inflammability, and the causation of cere- 
bral excitement, and nausea and vomiting. The pungency can 
be lessened if plenty of fresh air is given with the first few in- 
halations until the patient is partially accustomed to the sensa- 
tion of suffocation. The inflammability is only of importance 
while operating in the presence of a flame or with a cautery. In 
such cases the danger can be reduced by having the light set high 
up, as the ether vapor is heavier than air and no explosion is 
possible until it reaches the level of the flame. If the vapor does 
take fire cover the patient's nose and mouth with a towel or 



78 MINOR SURGERY. 

gauze. If a cautery iron is used about the face take away the 
inhaler and fan away the vapor before bringing the cautery near. 
The cerebral excitement may be due to the effects of the drug or 
be caused by the surroundings. It may be partially avoided by 
assuring the patient that he will be well taken care of and is not 
in serious danger. 

The Administration of Ether. — Numerous inhalers have 
been devised for the administration of ether, each one having 
some good point. An effective ether cone can be improvised with 
a towel and newspaper. The method is as follows: Take three 
layers of paper two feet in length and eighteen or twenty inches 
in width, together with a towel two inches longer than the paper 
in each diameter. Place both on a table, the towel underneath, 
fold them in the middle of their long diameter so as to bring the 
cloth on the outer surface and the paper within. Then fold them 
in the short diameter, the length of the fold corresponding to the 
distance from the chin to the root of the nose of the patient. 
When thus folded wrap around the fold the remainder of the 
material and pin the outer and inner extremities firmly through 
the whole texture of the sides. One end should be closed by 
pinning the turned-in edges to each other. Into the top of the 
cone can be packed a good sized sponge or cotton on which is 
poured the ether. This cone has the disadvantage of not permit- 
ting the regulation of the amount of air and ether to be given, 
though if caution is exercised these objections are overcome. 
The tissues should be smeared with some greasy substance to pre- 
vent burning and the cone, into which is poured a few drops of 
ether, is applied, and the patient told to take a few breaths. The 
cone is then removed and the patient given air. This is repeated, 
the amount of ether being gradually increased. Never suddenly 
add a large amount of the drug, as it causes coughing and vomit- 
ing. When the patient is accustomed to the odor and the mem- 
brane to the irritation of the drug, the cone should be firmly 
adapted so as to exclude all air. At this time there may begin 
what is called the stage of excitement. The patient may struggle, 
and there may be present a disturbance of respiration and pulse. 
This stage may continue for five or six minutes and then termin- 
ate rather abruptly; the muscles become relaxed and the patient 



SURGICAL ANESTHESIA AND ANESTHETICS. 79 

breathes regularly and often loudly. Some surgeons give an in- 
jection of morphine if the stage of excitement is prolonged. 
Alcoholics, as a rule, take any anaesthetic poorly. They are apt 
to become rigid and very cyanotic from spasm of the muscles of 
respiration during this stage. Tremor also occurs and is annoy- 
ing. 

The pulse should be full and steady unless the influence of the 
drug is waning or the patient is about to vomit, when it becomes 
weaker and faster. Aftej the patient is fully anaesthetized no 
more of the drug should be given than is necessary to keep the 
patient quiet. This is effected by pouring into the cone small 
quantities at a time. Should vomiting threaten, forcing the ether 
for a moment will check it. If not, the cone is removed, the 
head turned on one side, preferably the right side, and when 
vomiting subsides the mouth is wiped and the cone reapplied. 
A method to ascertain whether the patient is sufficiently under the 
influence of the drug to allow the operation to commence is to 
quickly flex and extend the patient's elbow a few times, when if 
he is not under there will be a certain amount of resistance, 
while if ready the motion will be free and the arm is limp. 

The accidents are to be watched for and treated as they present. 

Occasionally chloroform and ether are employed for the same 
patient during one operation. Chloroform being given first in 
order to avoid the irritation of the mucous membranes. Ether is 
given later on to lessen the depressing action of chloroform. 

Anesthetic for Children. — In children ether is, in general, 
the safer anaesthetic. Chloroform is especially dangerous in 
children who have been weakened by any inherited or acquired 
dyscrasia or from improper nourishment, and great care should 
be taken to prevent a too rapid administration of this agent when, 
as is frequently the case, the little patient begins to struggle and 
make rapid and deep inspiratory efforts. In children over twelve 
years of age, well nourished, with no serious lesions of the kid- 
neys or respiratory apparatus, chloroform is as safe as ether. 

a. c. E. MIXTURE. 

This fluid is composed of one part pure ethylic alcohol, two 
parts of pure chloroform, and three parts of pure ethylic ether. 



80 MINOR SURGERY. 

This mixture was introduced as being a really diluted chloroform, 
and was said to be without the dangerous properties of pure 
chloroform. Its extended use, however, has not proven this 
claim. 

For the administration of this fluid an Esmark inhaler or an 
ether cone may be used. It is better to use small quantities 
frequently rather than large ones occasionally when the cone is 
used. If an Esmark inhaler is used the administration by the 
drop method is recommended. 

The A. C. E. mixture irritates but little the sensitive respira- 
tory mucous membrane of the young and old. 

schueich's anesthetic mixture. 

This mixture, composed of ether and chloroform brought to a 
boiling point, is claimed by the originator to be safer and more 
comfortable to the patient. The claim is based on the relation of 
the boiling point of the anaesthetic to the rapidity of evaporation, 
the more rapid the evaporation the greater the comfort and less 
danger ! 

The following three mixtures are in use: 

No. i. Chloroform, 45 parts; petroleum ether, 15 parts; sulph. 
ether, 180 parts; boiling point, 100. 2 F. 

No. 2. Chloroform, 45 parts; petroleum ether, 15 parts; sulph. 
ether, 150 parts; boiling point, 104 F. 

No. 3. Chloroform, 30 parts; petroleum ether, 15 parts; sulph. 
ether, 80 parts; boiling point, 107. 5 F. 

The boiling point of the petroleum ether should be between 
122 and 140 F. An ounce of the No. 1 mixture is sufficient 
for an operation lasting twenty minutes. The longer the opera- 
tion is likely to be the higher should be the boiling point of the 
anaesthetic, as such anaesthetics evaporate less rapidly and so 
have a deeper and lasting effect on the patient. This mixture is 
given in the same manner as chloroform, and the same dangers 
are to be watched for. 

NITROUS OXIDE, OR LAUGHING GAS. 

This is the safest agent for producing general anaesthesia, but 
unfortunately its effects are of such a transitory nature that it is 



SURGICAL ANESTHESIA AND ANESTHETICS. 8 1 

not always practicable to use the gas for surgical procedures, and 
the cumbersome apparatus required for the generation further 
militates against its common use. Nitrous oxide is agreeable to 
the patient as well as safe, and the obnoxious after symptoms so 
often found following chloroform and ether are avoided. 

The administration of this agent in the past has been limited to 
dentists who administer it for the extraction of teeth. Irately 
the gas has been used in even major operations, and anaesthesia 
obtained for an hour or more with no bad results. In some hos- 
pitals the gas is administered for diagnostic purposes when there 
is apt to be considerable pain, and for minor operations where a 
local anaesthetic is not practicable. In patients afflicted with 
cardiac disease, phthisis or kidney disease, nitrous oxide is a safe 
anaesthetic. The gas is kept in mental cylinders and requires a 
special apparatus for its administration. 

Rectal Etherization. — It is possible to obtain general anaes- 
thesia by the administration of ether by the rectum. While this 
method for a short time was well tried the results did not warrant 
its continuation, though it is occasionally used for special cases. 
The ether is placed in a bottle provided with a tightly fitting 
cork, through which passes a rubber tube. The free end of the 
tube is inserted in the rectum and the bottle placed in warm 
water ioo° F. As soon as anaesthesia is obtained the tube is 
withdrawn from the rectum, though it may be reapplied if neces- 
sary. There is a danger of the patient being too profoundly 
anaesthetized, and the contact of the ether with the intestinal 
mucous membrane may cause a bloody diarrhea. 

Inebriation. — In some instances where an anaesthetic is dan- 
gerous to life a patient may, while under the influence of the 
stronger liquors, become partially insensible to pain, and needed 
operative measures carried out. Such cases are those who have 
been weakened by chronic disease or those in shock. An ounce 
or two of whiskey or brandy given in hot milk or hot beef tea 
every hour for four or five hours will bring on a state of intoxica- 
tion, and then if an anaesthetic is decided upon only a small 
quantity will be required. Much can be done with a local anaes- 
thetic under similar conditions. 

Rapid Respiration. — A slight degree of anaesthesia may be 
6 



82 MINOR SURGERY. 

produced by taking several long, deep inspirations repeated rap- 
idly. This acts by causing an accumulation of blood in the 
veins, overcharging the vessels of the brain with imperfectly 
oxygenated blood, thereby stupefying the sensibilities. It is 
recommended for opening abscesses and where small incisions are 
required. One objection to it is the danger of apoplexy from the 
engorged blood vessels of the brain. 

Oxygen with Anesthesia. — Oxygen gas is often adminis- 
tered combined with a general anaesthetic. It is said to reduce 
the dangers of anaesthesia and also the unpleasant after effects. 
A special inhaler is necessary for its administration. We have 
found that more time is necessary to put the patient under the 
influence of either drug with the combination. 

LOCAL ANESTHESIA. 

There are numerous agents in use that will cause local anaes- 
thesia. In general, if the proper technique is observed a local 
anaesthetic will control pain in quite formidable operations. In 
cases where the patient's condition is such that a general anaes- 
thetic is contraindicated, local anaesthesia has a distinct field of 
its own. It is commonly used in the probing of wounds, incising 
boils or carbuncles, opening buboes, cysts, abscesses, felons, 
removing ingrowing toe-nail, foreign bodies, teeth, small tumors, 
warts, hemorrhoids, operations for phimosis, paraphimoses and 
about the nose and throat, in the urethra, and amputation of toes 
and fingers. A large number of operations may be performed 
with the aid of local anaesthesia. Amputations of the hip and 
amputations of less importance, laparotomies, for tumors and per- 
foration of the intestines, cystotomies, herniotomies and other 
major operations have been almost painlessly performed with 
hypodermic injections of one of the drugs used for the purpose. 
The field is a large one and is being rapidly cultivated. The 
local anaesthetics more commonly used are Cocaine, Beta eucaine, 
Nirvani, Chloretone, Ethyl chloride, ice and ether. 

Cocaine hydrochlorate is perhaps the most widely used drug. 
It is used in solutions of varying strength and applied to mucous 
and cutaneous surfaces, and injected into the tissues beneath. 



SURGICAL ANESTHESIA AND ANESTHETICS. 83 

For operations in the nose and throat solutions of from 2 to 10 
per cent, are applied on small pledgets of cotton or by an atom- 
izer. For the subcutaneous injections the strength of the solu- 
tion is selected according to the amount to be injected and the 
character of the operation. We have found that a 2 per cent, 
solution will deaden the sensibility of the skin, and that a 1 per 
cent, solution injected under the skin will anaesthetize the deeper 
tissues. 

The disadvantages of Cocaine are its sudden depressing effect 
upon the heart, which may cause fatal syncope. There are 
numerous cases on record where death has come quickly follow- 
ing the use of the drug. If the part to be operated permits, it is 
well to pass a constricting band of some material above the injec- 
tion. This procedure limits the action of the drug to the part 
operated, and also prevents a too rapid absorption of the Cocaine 
by the general circulation. The bandage or rubber tubing used 
for constriction if loosened a trifle at a time will allow but a small 
amount to be taken gradually into the circulation, and so tend to 
avoid the dangerous Constitutional effects. The needle puncture 
should only be made when the skin and needle have been asepti- 
cized. If a fine needle is used for the work the initial puncture 
will be almost painless. To obviate the pain of the puncture a 
piece of ice held on the skin for a minute will anaesthetize this 
tissue. The spray of Ethyl chloride is very satisfactory for the 
same purpose. The needle is to be inserted at such a point as 
the judgment of the surgeon decides will have the desired effect 
on the part to be incised. A drop or two only is injected at the 
first puncture, the tip of the needle entering the skin but not 
going into the deeper tissues. Wait three minutes and then 
make a % inch incision, or longer if needed, and the cut is not 
painful. Another injection of two drops is then given and then 
more dissection. This procedure is repeated alternately, injecting 
and cutting, until the operation is finished. One should not inject 
over ten drops of even weak solution of Cocaine into the tissues 
at one puncture, because of the unpleasant results already men- 
tioned. Some persons can bear larger quantities of the drug than 
others, but we have no method of determining who they are, and 
again, weak solutions frequently injected are as effective and, 



84 MINOR SURGERY. 

eminently safer than the stronger solutions. The application of 
Cocaine to the urethral mucous membrane is peculiarly danger- 
ous, sudden death having followed its use in this area. Very 
weak solutions should be employed in small amounts in the 
urethra for this reason. 

Eucaink B. — This drug is used for exactly the same purposes 
as Cocaine. The technique for its application is the same, and 
the agent is said to possesss an advantage over Cocaine, in that 
the action of the drug on the heart and circulation is not so de- 
pressing, and therefore safer and not so liable to cause cardiac 
failure. While a much safer drug, its action is somewhat slower 
than that of Cocaine. It may be used in from i to 3 per cent, 
solutions, which may be sterilized by boiling without causing 
changes in the drug. As much as a hundred drops may be ad- 
ministered during a single operation by injection into the skin. 




Fig. 18. Infiltration Anaesthesia. The syringe point stops at the papillary layer, 
and the fluid lodges in the skin itself. 

SchIvKich's Infiltration Anesthesia. — Weak solutions of 
different combinations of Cocaine, Morphine and common salt 
plentifully diluted with water can be used in large amounts for 
anaesthetic purposes. There are three solutions used in different 
strengths- 
No. I. SOLUTION — STRONG. 



Cocaine muriate gr. 3. 

Morphine muriate • * . . gr. f . 

Soda chloride gr. 3. 

Distilled sterilized water oz. 3-f . 



SURGICAL ANESTHESIA AND ANESTHETICS. 85 



NO. 2. SOLUTION — NORMAL. 



Cocaine muriate gr. 1 } . 

Morphine muriate gr. §. 

Soda chloride gr. 3. 

Distilled sterilized water oz. 3§. 

NO. 3. SOLUTION — WEAK. 

Cocaine muriate gr. -\. 

Morphine muriate . . ^ gr. f . 

Soda chloride, gr. 3. 

Distilled sterilized water oz. 3! . 

Solution No. i is employed for the most painful operations, 
and as many as 6% drachms can be used at one operation. 

Solution No. 2 is employed for less painful operations, and 3^ 
ounces can be used during the procedure. 

Solution No. 3 is injected into the deeper and less sensitive 
tissues, and used in extended operations. In this strength a pint 
can be used at a time. 

These mixtures are injected as before described, except that 
larger quantities can be forced into the skin and deeper tissues. 
The introduction of 5 to 10 minims of the milder solutions causes 
a wheal to form. If this is incised it will be without pain. The 
area of anaesthesia is advanced by repeated injections placed at 
the edge of the preceding wheals. The deeper tissues can be 
injected in the same manner, though the wheals will not be so 
pronounced. 

Nirvanin, Orthoform and Chloretone are recent drugs advanced 
to supercede the use of Cocaine. It is claimed that weak solu- 
tions of these drugs will do all that Cocaine will accomplish and 
without the unpleasant accidents. 

Orthoform is recommended as an effective sedative to irritated 
nerve endings, while Chloretone is largely being used by dentists 
for the painless extraction of teeth, in one per cent, solution. 

Ice, Ether and Ethyl chloride freezing a part will temporarily 
benumb it. Powdered ice two parts and salt one part enclosed 
in cheese cloth laid directly on the skin for five or six minutes 
will produce total insensibility of the part. 



86 MINOR SURGERY. 

Ethyl Chloride, — This agent is a volatile liquid that if 
sprayed upon the tissues rapidly evaporates and causes intense 
cold. Ether has the same effect. Cold acts by causing a tem- 
porary constriction of the lumen of the capillaries and a conse- 
quent temporary death and insensibility of the part. The general 
circulation is not affected, and as the agent is applied for but a 
short time, the blood returns to the part and complete restoration 
takes place. The Chloride of ethyl is sold for the purpose in 
glass tubes, so that a definite amount can be applied, and the 
tube then closed for its further use. 

Local anaesthesia of the skin may be obtained by drawing a 
camel hair pencil, wet with Carbolic acid, 95 per cent. , over the 
line of incision. Ice water injected hypodermically will produce 
results nearly as good as those obtained by using the infiltration 
anaesthesia. 

Peroxide of hydrogen injected under the skin produces an 
immediate and complete anaesthesia of the whole area. Absorp- 
tion does not take place, as the intercellular induction from the 
gas generated seems to produce such pressure that the skin cuts 
like frozen tissue. 

SUBARACHNOIDEAN INJECTIONS OF COCAINE AS A 

SUBSTITUTE FOR GENERAL, ANESTHESIA 

BELOW THE DIAPHRAGM. 

This subject has attracted much attention in the last two years, 
and a consideration of its experience and results ought to be desir- 
able. Dr. Corning, an American, demonstrated in 1884 that 
anaesthesia could be produced in this way. Lately it has been 
often practiced, and is now undoubtedly a practical method of 
producing anaesthesia so that even major operations in the ab- 
domen and lower extremities can be performed without pain. 
Its advantages are its easy application, thorough analgesia of all 
the tissues below the diaphragm, the retention of the sense of 
touch, the absence of the reflexes, the consciousness of the 
patient, the avoidance of one of the greatest dangers to surgical 
procedures at the present time, namely, the primary, intermediate 
and secondary sequences of the anaesthetic, as cardiac, renal and 
pulmonary disturbances. 



SURGICAL ANESTHESIA AND ANESTHETICS. 87 

The major operations performed without pain include hyster- 
ectomies, nephrectomies, intestinal resections and gall bladder 
operations, amputation of the hip and others. The technique 
given below is the one used by Prof. Turner. 

A Pravaz syringe admitting of sterilization is used. This is a 
hypodermic with an asbestos piston. The needle must be of 
platinum, easily sterilized and 9 cm. long. It must be solid so 
as not to bend when it comes in contact with the vertebral 
column. Its end must have a short bevel. A two per cent, solu- 
tion of Cocaine is employed. This solution must be sterile and 
fresh. Old solutions must not be used. The patient is in a sit- 
ting posture, both arms carried forward. The field of injection 
is thoroughly asepticized. Locate the iliac crests. An imaginary 
line connecting these two crests passes through the fourth lumbar 
vertebra. B}^ injecting beneath that line you penetrate the 
medullary canal. As soon as you have located with the left 
index finger this spinous process, tell the patient to bend forward 
so as to make a big bag. This bending forward causes a separa- 
tion of 1.5 cm. between the vertebra on which you have your 
index finger and the subjacent vertebra. Then it is always wise 
to tell the patient, " I am going to stick you with a needle; you 
will feel some pain, but do not move." Make the injection with 
the right hand. Insert the needle to the right of the vertebral 
column, about 1 cm. from the line of the spinous process. The 
needle goes through the skin, through the subcutaneous cellular 
tissue, through the lumbar aponeurosis, through the muscles of 
the sacro-lumbar region, and penetrates into the lamellar space, 
and at last penetrates into the spinal canal. As soon as the 
needle is in the subarachnoid space it meets no resistance, and 
from it escapes a clear, yellow liquid. This fluid is the cerebro- 
spinal fluid, and escapes drop by drop. The surgeon must never 
inject a solution of Cocaine before he has seen the cerebro-spinal 
fluid escape through the needle. After he has seen this fluid 
escape through the needle, he attaches to the string a syringe 
containing 1 c.c. of a two per cent, solution of Cocaine. The in- 
jection is made slowly; it should be completed in one minute. 
The dose injected should not exceed 15 milligrams of Cocaine. 
Always employ a two per cent, solution. The injection termi- 



88 MINOR SURGERY. 

nated, rapidly remove the needle and close the needle puncture 
with sterilized collodion. Note the precise minute at which the 
injection is terminated, and then wait. The patient can be ques- 
tioned as to the subjective sensation which he experiences. 
After a certain lapse of time, which in our observations varied 
according to the subjects from about four to eight or ten minutes, 
the patient would complain of a tingling sensation and numbness 
of the feet. This numbness extends to the legs. One can now 
begin to operate. Gradually the sensation of pain and heat dis- 
appears. Contact sensation persists. Toward the last the motor 
system may be affected. From four to ten minutes after the 
injection analgesia is usually complete. More often it extends to 
the thorax, occasionally to the axilla. It is a complete and 
absolute anaesthesia. The duration of analgesia is from one to 
one and one-half hours. This allows sufficient time to complete 
the most laborious surgical intervention. 

In subjects whose spinal column is deviated, as in scoliosis, the 
line of the spinous process can only be found with difficulty, and 
owing to the fact that the vertebral laminae have lost their normal 
relations, the puncture may be difficult. This obstacle, however, 
can be overcome by patience on the part of the operator. If the 
needle strikes against a vertebral lamina change the direction of 
the point, either upward or downward, but do not pull it back 
and forth. This pulling back and forth of the blunt needle 
may succeed in breaking it. The better thing to do is to remove 
the needle. Make another puncture higher up or lower down. 
The solution must be injected in the subarachnoid space. 

The immediate dangers of subarachnoid injections seem to be 
slight. Several deaths have been reported after this method of 
anaesthesia, but a careful analysis does not show that they were 
directly due to the local anaesthetic. Usually the patients com- 
plain of epigastric weight, a feeling of epigastric coldness. They 
are anxious, complain of headache, and may be nauseated. 
These symptoms may occur during the operation, a few minutes 
after the puncture, but usually in the hours that follow the punc- 
ture. Depression not infrequently follows, due to the toxic action 
of the Cocaine. Profuse sweating, dilation of the pupils, shaking 
of the limbs and fast pulse are also noticed in some cases. All 
these accidents disappear in twenty- four hours after the operation. 



SURGICAL ANESTHESIA AND ANAESTHETICS. 89 

As to the remote dangers practically nothing is known. It 
may be that weeks or months after the injection degenerative 
processes will be set up. This is improbable, as the injection is 
not made into the spinal cord, but merely into the subarachnoid 
space, and is there brought into contact with the nerves after 
they emerge from the spinal cord. 

Spinal anaesthesia is very attractive from a surgical point of 
view, and may lead to a method which will add to the safety of 
anaesthesia. Whether or not this plan will supercede the usual 
methods of obtaining anaesthesia remains to be seen. It is not a 
procedure that can be recommended for every day use because of 
the liability to cause infection of the canal. In obstetrics as well 
as in surgery the method has been extensively tried and with 
remarkable results. Painless labor has been the result where the 
injections have been given. 

Kucaine B. has been tried in place of Cocaine, but the effect 
was not so good. 



CHAPTER XII 



MINOR SURGICAL MISCELLANY. 

LUMBAR PUNCTURE. 

This procedure has been advanced as being of value both for 
diagnostic and therapeutic purposes, and is now recognized as a 
useful adjunct to the regular methods. In certain diseases of the 
spinal canal a hypodermic needle introduced into the subarach- 
noid space will allow the escape of fluid, which, on microscopical 
examination, permits more clear understanding of the pathologi- 
cal condition present. In the same class of affections the punc- 
ture may be used in a similar manner to draw off part of the effu- 
sion in the membranes, and so have a therapeutic effect. The 
operation of lumbar puncture should only be made under the 
strictest aseptic precautions, and when absolutely necessary. It 
is a minor operation, but much harm might result if infection 
occurs as a result of careless technique. 

Technique. — The choice of location at which the puncture 
should be made may be governed by the consideration of the fol- 
lowing requirements: 

i . That the needle shall find an easy entrance to the subarach- 
noid space. 

2. That the tapping be made at the point least likely to admit 
of damage to the nervous structures of the canal. 

3. That the fluid obtained shall be as rich in sediment as 
possible. 

The first requirement is sufficiently well met by entrance 
through any of the lumbar spaces or through the lumbo-sacral 
space. Injury to the cord can be avoided by entering at some 
point below the third lumbar vertebra. In adults it is safe to 
make the puncture between the second and third vertebrae. The 
lumbo-sacral space will produce fluid with the most sediment. 
If the puncture is made for diagnostic purposes it is best to enter 



LUMBAR PUNCTURE. 9 1 

the lumbo-sacral space and to have the patient, if a child, in the 
sitting position. With adults, and especially those who are de- 
lirious and comatose, or who are greatly prostrated, it is often 
impracticable. The aim should be to secure the greatest possible 
degree of ventral flexion of the spine. The child must be bent 
well forward and firmly held if it is in the sitting position, and if 
lying down the patient should be made to curl up, with the knees 
and chin as near together as possible. General anaesthesia is 
very rarely necessary, for local anaesthesia will make the punc- 
ture almost painless. In an adult even a local anaesthetic is un- 
necessary. If the patient is in a delirium or very restless, two 
assistants will aid in securing the proper position and prevent 
sudden movements. If aseptic precautions are of value anywhere 
they certainly should be enforced in this procedure. The field of 
operation, hands and instruments should be thoroughly cleansed. 
For children an antitoxin needle four or five centimetres ( i ^ 
or 2 inches) long, and one millimetre in diameter, serves well. 
For adults the needle must be eight or nine centimetres long, and 
of sufficient rigidity to pass easily through the tissues. When 
the selected space is located, the interval between the spines is 
marked with the finger of the left hand, and the needle attached 
to the syringe is introduced at a point opposite the upper edge of 
the lower spinous process and in a line just outside. The needle 
is directed very slightly upward and toward the median line. As 
the needle passes through the interlaminar ligament, slight resist- 
ance is noticed and a sensation of grating is felt. Beyond this 
the needle slips in very easily, and is introduced until a few drops 
of fluid escape from the canal. If bony resistance is met in 
introducing the needle, the latter should be withdrawn for a 
slight distance and directed at a slightly different angle. When 
the fluid appears the syringe is taken off and the fluid collected 
in a sterile tube. It is better to let the fluid run from the needle 
than to draw it out with the syringe. If the puncture is made 
for diagnosis ten or fifteen cubic centimetres of fluid may be with- 
drawn. If for therapeutic purposes it may be advisable to remove 
several times this quantity. The safest guide should be the con- 
dition of the patient. If headache, faintness or changed pulse 
occur the needle should be withdrawn, often with some degree of 



92 MINOR SURGERY. 

force, and the puncture wound sealed with collodion, or sterile 
gauze and adhesive strap. Very few accidents have been reported 
as a result of this measure, and these have been trivial and unim- 
portant. 

ASEPTIC INJECTIONS. 

Subcutaneous injections are minor surgical operations that may- 
be of major importance, because of the possibility of causing in- 
fection due to a non-observance of aseptic rules. Before making 
an injection the skin of the patient as well as the hands of the 
surgeon should be rendered clean, exactly as when preparing for 
any other operation, and the fluid used must be sterilized. An 
all metal cylinder for the hypodermic syringe is best. This can 
be boiled and thoroughly cleaned, and the boiling does not im- 
pair its usefulness. The needles can easily be rendered sterile by 
being boiled in a soda solution. If they are made of platinum 
they can also be sterilized in the flame of an alcohol lamp or on 
being held over a gas or match flame. The observance of these 
simple precautions will prevent the occurrence of the small fur- 
uncles that so often arise after an injection, and are due to faulty 
technique. 

Hypodermic injections are effective in conveying drugs under 
the skin and into the deeper tissues where they are rapidly ab- 
sorbed into the circulation. Stimulants, narcotics and local an- 
aesthetics may be introduced and their effects quickly produced. 
The portions of the body usually selected for hypodermic medica- 
tion are the outer surface of the thighs or arms, the anterior sur- 
face of the forearm, the neck and the abdomen. It is important 
that the needle should not be introduced in the region of vessels 
or nerves, as the too rapid absorption of the fluid by the blood- 
vessels, if entered, may result unpleasantly. 

The solutions may be prepared in a spoon or the bottom of an 
inverted tumbler and the syringe charged, and the needle is fast- 
ened to the nozzle of the syringe. The skin is next pinched up 
between the thumb and forefinger and the needle is quickly 
plunged into the cellular tissue. The syringe is emptied by forc- 
ing down the piston and the needle withdrawn. If a fine needle 
be used the pain is very slight. Only sterilized and freshly pre- 



ASPIRATION. 93 

pared solutions ought to be employed. Solutions can be almost 
immediately prepared by the compressed tablets sold by the man- 
ufacturing chemists, and boiled water. 

EXPLORING NEEDLE AND TROCAR. 

An exploring needle is one with a fine groove that is attached 
to a handle and so introduced into tumors or joints in order to 
prove the nature of the contents. The fluid, if present, is shown 
in the groove of the needle^ and is of service for diagnostic pur- 
poses. The trocar is a firm needle in a metallic cover. When 
used the cover, or canula, and needle are introduced together, 
the needle is then withdrawn, the canula being left in position, 
and the contained fluid allowed to escape. Before either the ex- 
ploring needle or trocar are introduced the skin of the patient, 
instruments, and the hands of the operator should be carefully 
cleansed. If these precautions are not observed unpleasant com- 
plications may occur in this procedure, which is otherwise free 
from danger. Care should be taken not to introduce either in- 
strument into a blood-vessel or nerve. 

ASPIRATION. 

In certain cases, where there is present much effusion, such as 
occurs in pleurisy, empyema and tubercular and other fluids in 
joints, it is often necessary to remove the fluid by aspiration. An 
aspirator is the instrument used for this purpose; it consists of a 
glass cylinder and a long, slender, hollow needle, which is con- 
nected with the cylinder by a small rubber tube. The needle is 
introduced into the cavity, the piston drawn slowly out, and thus 
forces the fluid into the cylinder. The best instrument for the 
purpose is the pneumatic aspirator, or Potain's, which consists of 
a glass bottle, the stopper of which contains a metallic tube, 
which is connected with two rubber tubes, one of which is at- 
tached to an air-pump, and the other to a fine trocar or canula. 
Two stopcocks in the metallic tube control the admission of air. 
The air is exhausted from the bottle by about forty strokes of the 
air-pump, and the canula and trocar are then introduced through 
the tissues into the cavity. The trocar is then drawn out and the 



94 



MINOR SURGERY. 



stopcock leading from the bottle to the canula is turned on, and 
the fluid is drawn out of the cavity by atmospheric pressure and 
passes into the bottle. If the canula or needle become obstructed 
a wire stylet may be passed through the canula and relieve the 
blockade. Of course, the skin, apparatus and hands of the op- 
erator should be well cleansed before the operation is commenced. 
In sensitive persons the puncture may be rendered painless by 
Ethyl chloride spray, or the application of a towel containing 
broken ice and salt. 




Fig. 19. Aspirator and Injector. 



As in all cutaneous injections, the operator must be careful to 
avoid wounding vessels and nerves. After the operation is com- 
pleted the puncture may be dressed with a small piece of steril- 
ized adhesive plaster or piece of gauze held in place by an adhe- 
sive plaster strap. 



STOMACH TUBE. 95 

STOMACH TUBE AND LAVAGE. 

The Stomach Tube. — This consists of a flexible rubber tube 
about thirty inches in length, which is introduced into the stom- 
ach as required for the evacuation of poisons, and also to wash 
out this organ. The tube may be passed with the patient in the 
sitting posture or the recumbent position. When possible the 
head should be thrown backward so as to bring the mouth and 
oesophagus as nearly as possible in the same line. The tube is 
warmed and oiled and is tl^en passed back to the pharynx, and is 
guided over the epiglottis by the index finger of the left hand; it 
is then pressed gently into the stomach; very little force should 
be used for fear of injuring the oesophagus. If the patient has 
taken poison this may be withdrawn and the stomach washed out 
by the use of the tube and syringe. The stomach is injected with 
warm water and then withdrawn by the suction of the syringe. 
The stomach tube is also of aid in conveying nourishment to per- 
sons who are unable to swallow or will not, as often happens 
among the insane. In such a case liquid food can be injected in- 
to the tube through a syringe, or by the aid of a funnel, and per- 
mitted to run into the stomach. 

Stomach Lavage. — This procedure is a valuable adjunct in 
the treatment of certain diseases of the stomach and duodenum. 
It consists of the introduction into the viscus of a flexible rubber 
tube of different sizes that is warmed and lubricated either with 
vaseline, sweet oil or milk. The operator stands in front of the 
patient with the tube in his right hand; the patient inclines the 
head backward and the point of the tube is passed over the lar- 
ynx; the patient is told to make efforts to swallow, and the tube 
is gently forced down into the stomach. If the pharynx is irrit- 
able the application of a 4 per cent. Cocaine spray may aid in the 
passage of the instrument. A pint of warm water or weak Boracic 
acid solution is then poured into the elevated rubber funnel at- 
tached to the end of the tube and allowed to run into the stomach. 
The funnel and tube outside the mouth are then lowered and the 
stomach contents siphoned out. This procedure is repeated until 
the fluid returns clear. 

The Stomach Pump. — This instrument consists of a metallic 
syringe and two tubes, one of which is connected at the end and 



96 MINOR SURGERY. 

the other at the other side of the cylinder. A valve regulates the 
passage through the end or nozzle. The nozzle is attached to a 
rubber stomach tube, and the end of the side tube is placed in a 
bowl of warm water. If the piston is withdrawn and the valve 
opened water is drawn from the basin, and if the valve is closed 
and the piston pressed down the water is forced into the stomach. 
The stomach is emptied by reversing the procedure, and the fluid 
escapes through the lateral tube into the receptacle. 

VACCINATION. 

Though in vaccination absolute asepsis is impossible, as the 
lymph would be rendered inactive, this procedure, which every 
physician is called upon to perform, requires that the skin and 
instrument be cleansed. The lymph now used is the bovine 
virus mixed with glycerine. Formerly ivory points were used as 
vehicles to carry the virus, but it is only a question of a short 
time when the ivory point will be a relic of the past. The most 
scientific method is the use of the hermetically sealed capillary 
tubes. When the points are used they are first dipped into water, 
which has been boiled and cooled down. This moistens the 
virus, which is then rubbed into the abraded surface and allowed 
to dry. If the glass tubes are used one end is broken and the 
virus dropped onto the prepared surface. Two places of inocula- 
tion at the same time are better than one. These two scarifica- 
tions, made two inches apart, do not make as sore an arm as one 
large scarification. It has been proven that two or more scars 
give greater immunity than one. The immunity obtained from 
two scars is greater for the time being, but does not last any 
longer than if only one scar was present. The site of the inocu- 
lation may be the outer surface of the arm just below the deltoid 
muscle, or on the lower part of the thigh. A simple rule may be 
formed, viz. : Arms for boys and legs for girls. 

The best results and the neatest and most typical scars are 
obtained by making small scarifications. The scarified place 
should be but little over T V of an inch square. It should never 
be greater than }i inch square. The scar is always larger than 
the original scarification, varying from }( inch to many times 
greater, depending on the manner in which it is done and the 



SKIN GRAFTING. 97 

patient operated upon. The surface to receive the lymph is first 
washed with soap and water, and then with a i to 2,000 bi- 
chloride solution, and finally with plain water to remove the 
bichloride. The surface is then scarified at two points one inch 
apart with a dull pointed knife that has been boiled in water. 
Several superficial scratches are made crossing each other until a 
drop or two of serum exudes. It is not desirable to draw blood, 
as this washes away the virus and prevents the desired end. 
The part may be dressed^ with a folded piece of sterile gauze held 
in place by adhesive plaster. A most useful dressing consists of 
an oval piece of perforated India rubber adhesive plaster large 
enough to cover both the insertions, on the inner side of which is 
a flat pad of dermatol gauze stuffed with wood wool. Two of 
these are sufficient; the first is fixed on directly after the vaccina- 
tion, the second when the first is removed for inspection a week 
later. A corn plaster or two may be used as a protective dress- 
ing. These are held in place by adhesive straps, and can be 
replaced if necessary. Occasionally a lump forms at the site of 
inoculation. This lump is spongy, about the size of a pea and 
red, covered at times b}^ a small scab. It generally remains a 
week or ten days or longer, and then dries up leaving no scar. 
Many pronounce such cases successful. This is not true, and the 
patient is not immune. Any vaccination to be successful must 
leave a scar. 

The patient must be cautioned about keeping the dressing in 
place and to return and have the part redressed at stated intervals, 
otherwise the wounds may become infected either immediately, 
when a possibly dirty sleeve is drawn over them, or later when 
the vesicles have burst. The death of a child from tetanus as a 
result of infection of a vaccination wound occurred in our clinical 
practice. The parents persisted in applying filthy rags to the 
part with the inevitable ending. Patients should be cautioned 
about dressing the vaccination with vaseline or any other oint- 
ment. The best results are obtained by keeping the sore per- 
fectly dry from start to finish. 

SKIN GRAFTING. 
The operation of skin grafting is often required to fill in spaces 

7 



98 MINOR SURGERY. 

where there has been a loss of the normal covering due to burns, 
extensive lacerations and other injuries, ulcers, etc., and also to 
hasten cicatrization of a denuded area. The idea of the operation 
is to take thin shavings of the epidermis, or of the epidermis and 
cutis combined, and apply them to a healthy granulating surface. 
These shavings or grafts are held in place for a few days. The 
surface to which the graft is to be applied must be clean, dry and 
aseptic. If granulations have already formed exudations must 
be cleared away and the granulations shaved away. The wound 
is then thoroughly washed with a sterilized salt solution or 
Thiersch's solution. Oozing of blood is checked by the firm 
application of a gauze compress which affords pressure until the 
grafts are ready to be put in place. This is important, as the 
gauze will prevent the formation of blood clots, which might 
separate the graft from the raw surface and so prevent what is 
desired. 

Thiersch's Method. — This operation is perhaps the more 
favored one of applying grafts. With this method the grafts are 
generally taken from the inner or front surface of the thigh. 
The skin is first scrubbed and shaved, and again scrubbed, then 
rinsed with alcohol and water that has been boiled and cooled 
down. The skin is made tense and smooth by pulling down 
the tissues with the hand placed upon the lower third of the 
thigh; the other hand manipulates a special razor made for the 
purpose. The razor's edge should go no deeper than the papil- 
lary layer of the skin, and is drawn downward towards the knee 
by short sawing motions. If adipose tissue should be taken up 
with the graft this piece should not be used, as the graft would 
not take. Thiersch's solution is used to gently trickle on the 
skin just in front of the razor in its downward course, and so 
serves to float the detached skin upon the broad upper surface of 
the blade. The size of the grafts and their number depend upon 
the size of the wounded surface to be covered. A broad-bladed 
razor will cut and hold a strip of skin six or eight inches long 
and one or two inches wide. The lower end can be cut with 
scissors. The tissue to be engrafted is then placed gradually on 
the wound surface, which has been previously prepared. The 
exposed end of the graft is gently placed at the margin of the 



SKIN GRAFTING. 99 

wounci, and the strip is unfolded gently from the razor blade 
while it is slowly drawn across the surface, with its inferior side 
in contact with the raw tissues. A pair of tissue forceps aid in 
the application of the grafts, and great care should be taken that 
no part of the graft is turned over and that every portion of the 
cut surfaces of both parts are directly in contact with each other. 
The operated area is then covered with strips of sterilized rubber 
tissue an inch wide, that have been washed in Thiersch's solu- 
tion, and applied side by .side, with overlapping edges. Clean 
gauze compresses wrung out in the same solution are placed over 
the rubber tissue and in turn are covered in with a larger piece of 
rubber tissue, and gently but firmly bandaged in place. The 
dressings may be changed in five or seven days, when the part 
should be dressed as at the first dressing. 

L/usk's Method. — The technique of this operation consists of 
the application of one of the stronger vesicants (Cantharides) 
until a blister is formed. The tissues are sterilized as described, 
and, when ready, the vesicle is punctured and the thin epidermis 
clipped off and applied to the raw surface of the wound by the 
under surface of the graft. Enough vesicles are formed to fill in 
the lost tissue. The field of operation is treated and dressed as 
in the Thiersch method. 

Another procedure is to pinch up slight bits of epidermis with 
a needle and snip them off with scissors; the raw surfaces are 
brought into accurate contact and dressed. 

At the first or second dressing, when either of the given 
methods are used, the grafts seem to have disappeared, but in a 
short time bluish- white points will take the place of the grafts, 
and these will become converted into individual cicatrices, which, 
as healing progresses, will coalesce and fill in the cavity. If the 
grafts are taken from a second person the donor ought to be in a 
first-class physical condition to secure the best results. We have 
seen large areas successfully filled in with grafts taken from the 
skin of frogs' bellies. 

Kratjse's Method. — The idea of this method is to apply one 
large piece of skin to fill up a cavity. The graft is sutured in 
place, and should be one-third larger to allow for contraction. 
The graft includes the different layers of the skin, though all the 
cellular tissue should be removed. 



Lof 



IOO MINOR SURGERY. 

SUPERHEATED DRY AIR BATHS IN SURGICAL 
AFFECTIONS. 

Hot air baths have been in use from a very early period, but 
during the past ten years great advances have been made both in 
their efficiency and sphere of usefulness. There is no doubt but 
that in the treatment of certain affections the use of hot dry air 
gives most excellent results. From an experience gained in the 
surgical clinic of the Cleveland Homoeopathic Medical College 




Fig. 20. Hot-Dry Air Apparatus 

covering several hundred unselected cases we do not know of one 
case but what was benefited, and of none that felt any ill effect 
from the high degree of temperature. Most excellent results 
have been obtained in the treatment of acute, chronic and gonor- 
rheal rheumatism (muscular and articular), acute gout, sprains, 



SUPERHEATED BATHS. 



IOI 



ankylosis, bursitis, periosititis, neuralgia, adhesions about joints, 
synovitis and old ulcers, etc. 

We have used the Betz machine, which consists of a metal 
cylinder lined with asbestos, opened at one end only. The open 
end is fitted with a cloth attachment to encircle the part that is 
to be treated; the air is heated by gas, gasoline or alcohol. A 
high temperature thermometer is fitted into it so as to indicate 




Fig. 21. Cross Section of Hot-Dry Air Apparatus, (a a) Air intakes. 
(b) Circulating air space, (e) Jacked space for products of combus- 
tion, {g) Treatment chamber, {m) Cork ribs. («) Perforations 
admitting hot air. (p) Gas burner. 



the heat of the treatment chamber. The part to be treated is 
wrapped in four to six thicknesses of blanket or, better, Turkish 
towelling, so as to absorb the moisture the instant it exudes from 
the surface of the skin. This moisture is turned into vapor by 
the hot air and fills the cylinder. To prevent saturation of this 
air it is allowed to escape at intervals through a stop-cock. At 
the same time fresh air is allowed to enter from below. The 



102 MINOR SURGERY. 

stop-cock is removed about every ten minutes during the treat- 
ment. If the air at any time becomes saturated, the patient will 
immediately feel a sudden access of heat, and then the vapor may 
be let out; or slight pressure on the towelling at the point of pain 
will relieve it, and the treatment may proceed without further 
interruption. It is an important point to wrap the part evenly 
with the absorbent towelling or blanket, otherwise perspiration 
lodging between skin and the absorbent towelling may get super- 
heated and cause a blister. In the local Betz apparatus the tem- 
perature is held at about 350 degrees Fahrenheit for one hour. 

Heat at this temperature is ordinarily well borne. Of course 
when the temperature reaches these high points care must be 
taken to avoid scalding the skin, but with reasonable care there 
should really be no danger. The following constitutional effects 
have been noted by those who have used this treatment at all 
extensively: 

1. A contraction and then a dilatation of the superficial blood- 
vessels. 2. The pulse increases in strength and in rapidity of 
from ten to twenty-five beats per minute. 3. The bodily tem- 
perature rises from one to six degrees Fahrenheit. There is a 
profuse acid perspiration. Almost immediate relief from pain. 
General sense of comfort. Stimulation of nerves and lymphatics. 
Increase in respiratory movements from two to six per minute; 
but nervousness and twitching if the patient is exposed too long 
to the heat. After a number of treatments are found, as second- 
ary results, increased excretion of uric acid, softening and absorp- 
tion of uratic and other deposits, reduction and sometimes relief 
of albuminuria in kidney and cardiac diseases; some loss of weight; 
improvement in some chronic skin diseases; temporary soreness 
and nervousness in gouty and rheumatic patients during absorp- 
tion of the deposits; debility if the baths were too prolonged. 

In the treatment of the aged by this method one should be 
careful or severe burns and subsequent oedema will result. For 
these 250 Fahrenheit is sufficient. 

PASSIVE MOTION. 

Passive motion consists in the manipulation of a limb whose 
usefulness has been impaired by too long confinement in one posi- 



PHLEBOTOMY. IO3 

tion, the result of sprains, fractures, dislocations and dressings. 
The movements consist of forcible efforts at flexion, extension and 
rotation of the part so as to simulate the normal joint movements. 
The motions should be carefully practiced, starting gradually and 
increasing the range of motion each day. In some cases intelli- 
gent patients can carry out the treatment themselves. The pain 
is not of such a character that a general anaesthetic is required, 
though one is often given, and the existing adhesions broken up. 
In cases of fracture the motions should not be commenced until 
good union is assured, which usually occurs in about four weeks. 
If this treatment is well carried out many apparently future use- 
less joints may regain their normal action. 

The application of dry hot air in conjunction with passive mo- 
tion gives much better results. 

BLOOD-LETTING. 

On rare occasions the physician is called upon to deplete the 
system of an excess of blood. This is accomplished by the open- 
ing of a vein to effect a constitutional depletion, while scarifica- 
tion, cupping and leeching bring about a local abstraction. 

PHLEBOTOMY, OR VENESECTION. 

In the times gone by this minor operation was considered of 
minor importance and, undoubtedly, was frequently indicated, 
just as it is infrequently at the present time. The veins selected 
for the procedure are the internal saphenous at the ankle, the 
median basilic and median cephalic at the anterior part of the 
elbow joint, and the external jugular vein. The region of the 




Fig. 22. Superficial Veins in Front of Klbow. 

elbow is ordinarily selected; the median basilic is the more dis- 
tinct and is the vein usually opened; it should not be punctured 



104 MINOR SURGKRY. 

too deeply, as nothing but the bicipital fascia separates it from the 
brachial artery. The median cephalic may be selected, but we 
should remember that under this vein lies the external cutaneous 
nerve. 

The arm above the elbow should be constricted with a bandage 
or tape drawn sufficiently tight to obstruct venous return. This 
causes a distention of the veins, and if the patient clench his hand 
tightly about a hard object, like a stick, the veins will become 
more prominent. 

The vein should be well defined by the finger and held in posi- 
tion by the thumb or finger placed just below the point of inci- 
sion. The skin in the region should be well cleansed, also the 
knife for the incision. The incision is made obliquely to the 
transverse diameter of the vein, and of sufficient depth to divide 
two-thirds of the vessel. 




Fig. 23. Incisions for Venesection. 

If the patient works his fingers strongly on the stick the flow 
of blood will be increased. If the flow is obstructed by the sub- 
cutaneous fat, this should be pushed aside. The amount of blood 
taken will be determined by the condition of the patient. Usu- 
ally from one-half a pint to one pint will be all that is necessary. 
When faintness begins the constricting agent above the elbow is 
removed and the flow is arrested by the return of the blood into 
the normal channel and the bleeding point. A small compress of 
clean gauze is placed over the incision, and held in position by a 
bandage or adhesive plaster, so applied as not to impede the ve- 
nous return. 

The antiseptic management of venesection is important, as bent 
arm, due to suppurative cellulitis and suppurative thrombosis, 
followed by fatal pyaemia, has occurred not infrequently. 



SCARIFICATION. IO5 

Scarification. — This procedure consists in making short and 
superficial cuts into inflamed tissue with a sharp-pointed knife. 
Care should be taken in making the incision to avoid wounding 
veins and nerves that lie near the skin surface. The incision re- 
lieves tension of the parts by allowing blood and serum to escape 
from the congested tissues. If necessary, hot compresses over 
the incision will aid in depletion. 




Fig. 24. Scarificator. 

Scarification is often used in surgery where there are inflamma- 
tory conditions of the skin and cellular tissue, and acute inflam- 
matory swellings, such as glossitis, tonsillitis, cellulitis; chronic 
ulcers that refuse to heal are often benefited by scarifying the 
edges thoroughly. 

Deep incisions are needed where there is a considerable amount 
of acute inflammatory conditions, and one or several long and 
deep incisions are then necessary to drain the tissues. The deep 
incisions are required in phlegmon, carbuncle, furuncle, cellulitis 
in urinary infiltration, to prevent sloughing, and phlegmonous 
erysipelas. Conditions which require deep incisions are of rapid 
formation and a destructive type, and the incisions, to be of value 
in checking it, must be made freely and early. 

Leeching. — Three varieties of leeches are used to abstract 
blood. They are the Swedish leech, which draws three or four 
teaspoonfuls of blood; the American leech, which draws one tea- 
spoonful of blood, and the mechanical leech, which produces the 
same effect artificially. 

The skin should be cleansed properly before the leech is ap- 
plied. The leech may be picked up with tissue forceps and 



io6 



MINOR SURGERY. 



placed upon the part to be depleted. Sometimes they will not 
take hold as desired, but a few drops of blood or milk spread on 
the skin will bring about the end in view. The leech can be con- 
fined to the part by the open end of a test tube or glass tumbler 
placed over it. As soon as the leech has drunk its fill it will let 
go voluntarily and drop off. When it is desirable to remove the 
animal before it lets go its hold, snuff or common salt sprinkled 
over it will accomplish this. Several leeches can be used about 
the part at once, but should not be used a second time. 




Fig. 25. Hourteloup's Artificial Leech. 

If it is desired to prolong the bleeding after the leeches have 
finished, warm compresses of gauze applied over the site will aid. 

Where leeches are required in or near a mucous cavity as the 
mouth, rectum or vagina care should be taken that they do not 
escape into the cavities. 

Leeches should not be used directly over the inflammatory area, 
but should be applied to the parts immediately adjoining. Care 
should be taken that leeches are not allowed to bite directly over 
a superficial vessel or nerve. Occasionally rather too free and 
prolonged bleeding results from the leech bites. In such an event 
compresses of hot water may control it, or if this fails sty pics 
may be necessary, or a deep suture may be required, also acu- 



TRANSFUSION. 107 

puncture. The point of a steel knitting needle heated to a dull 
red heat applied to the bleeding point may be used. 

Leech bites should be irrigated with an antiseptic solution and 
dressed with antiseptic gauze compresses, held in place by a 
bandage. • 

The mechanical leech consists of a scarification cup and air 
pump in combination. It is not any more effective than the 
natural leech, but is useful when the animal can not be obtained. 
In using this instrument the scarificator is first manipulated, and 
then the piston of the air pump is drawn out slowly in order to 
secure a better flow of blood. 

Cupping. — This may be either dry or wet. Dry cupping is 
effected by using a cupping glass or tumbler, the interior of 
which has been previously heated with an alcohol lamp or a 
piece of burning paper. The glass is then inverted and applied 
to the affected area. The skin becomes congested and rises in the 
glass. In dry cupping the blood is simply drawn to the surface 
and not withdrawn from the tissues. It is, however, taken from 
the inflammatory area, and the effect is the same as if the blood 
was taken out of the body. 

Special mechanical devices are sold for this purpose. The 
Allen Surgical Pump is perhaps the best apparatus. 

Wet Cupping. — As the name implies, this method abstracts 
the blood from the body. A method is to scarify the part with a 
knife and apply the cupping glass as has been described. 

The degree of suction and depth of the incisions determine the 
amount of blood to be abstracted. Warm compresses applied 
favor bleeding. 

When the cupping ends an antiseptic dressing should be ap- 
plied. There is a special apparatus for this method of cupping, 
but the instrument is a complicated one and out of date. 

TRANSFUSION. 

Transfusion is a means employed to overcome the exhaustion 
caused by disease and shock from the loss of blood and injuries. 

In the treatment of shock due to hemorrhage transfusion is of 
inestimable value. Blood, defibrinated blood and saline solutions 
are the agents employed to meet the demands for transfusion. 



108 MINOR SURGERY. 

The saline solution has now almost entirely superceded the 
other agent, and is widely used for shock and hemorrhage, and 
also in certain diseases due to toxic influences, such as puerperal 
eclampsia, uremia, typhoid fever, etc. 

Saline fluids are easily prepared and their use does not expose 
the patient to many of the dangers sometimes due to the use of 
blood. The method of administering the saline solution so the 
immediate effects will result, is directly into the circulation. The 
intravenous way is the simplest and most efficient. Some sur- 
geons who realize the value of intravenous injection of salt solu- 
tion do not undertake an operation where there is apt to be 
severe hemorrhage or profound shock without being prepared to 
infuse at once. The injections can be given in conjunction with 
the other efforts at stimulation. 

The instruments necessary for infusion are a knife, a pair of 
small sharp rectractors, a thumb forceps, a canula, and an irri- 
gating bag bottle, glass funnel and a fountain syringe; cat-gut 
ligatures are also necessary. The fluid for infusing should be 
made with distilled water, except in emergencies, when if no dis- 
tilled water is to be had, boiled and filtered hydrant or rain water 
may take its place. The salt solution is prepared by the addition 
of a level teaspoonf ul of salt to each quart of water and the solution 
then boiled and filtered to strain the fluid of possible minute for- 
eign bodies that might obstruct the flow by clogging the canula. 

The normal salt solution is prepared by adding sodium chloride 
i}£ drahms, sodium bicarbonate grs. 15, to distilled water one 
quart. This makes a .07 per cent, solution. The solution should 
be used at a temperature of 1 io° F. The irrigating bag or bottle 
must be boiled in a soda solution and then rinsed with the salt 
solution to clear away the soda. 

If a rubber irrigating bag or fountain syringe is to be used, it 
and the tubing should be kneaded with the fingers and washed 
out. This is of importance in order to get rid of the powder 
which is nearly always found in new rubber. 

Although the operation of intra- venous infusion is a very simple 
one it requires, in order to be safe, the most rigid precaution to 
prevent the entrance of any foreign substances in the blood cur- 
rent. The medium cephalic or basilic veins are the ones usually 



SALINE SOLUTION. 109 

selected for the injection. A few turns of a roller bandage 
should be tightened about the patient's arm just above the elbow. 
This is tied so as to impede the venous return and the veins con- 
sequently below the constriction now fill and become prom- 
inent. The skin having been disinfected, a longitudinal incision 
is made over the disturbed vessel. The little wound should be 
then held apart by retractors and the vein clearly exposed for 
about three- fourths of an inch. The thumb forceps is then passed 
beneath the vessel and with its aid two ligatures of fine catgut 
are to be drawn through so that they shall lie beneath the vein 
and across it in a position read}^ for tightening. The two ligatures 
should be held up firmly, the upper one being drawn upward and 
the lower one downward so that the blood stream will be tem- 
porarily checked. A longitudinal incision is made into the vein 
between them. Into the opening the canula or blunt needle is 
inserted while the stream of saline fluids is running and not until 
the tube is emptied of air. 




Fig. 26. Intravenous Injection of Saline Fluid. 

Care should be exercised that the cannula should actually enter 
the lumen of the vessel and not force a way alongside of it nor 
between the vascular coats. If the vessel is not entered the fluid 
will distend the connective tissues adjacent to the point of en- 
trance. The upper ligature is then tied firmly, but with a bow- 
knot, around the canula in the vein, the lower ligature tied with 



IIO MINOR SURGERY. 

a full knot, and the tight bandage about the arm released to free 
the venous return. From one to one and one-half quarts of the 
saline solution may be allowed to flow into the circulation. The 
cannula should then be withdrawn and the ligature which was 
tied in the bow-knot should be slipped and the vein at once firmly 
tied with the usual square knot. The vein between the ligatures 
should now be divided, the cutaneous wound closed by a suture 
or two and dressed. As the fluid enters the circulation slowly it 
will be noted that there is a rapid improvement in the pulse and 
the patient's general condition usualty becomes better. Should 
the patient's condition later demand a second infusion, it had 
better be made through another vein, for it is dangerous to leave 
the cannula in position after the fluid has ceased to run, on ac- 
count of the formation of a blood clot, which, by another infusion, 
might be forced into the circulation, causing embolism. Air 
might also cause emboli under the same circumstances. 

A few hours after an infusion there may be a rise of tempera- 
ture or a slight chill. The cause of these phenomena is not 
known. 

Under no conditions should plain water be injected into a blood- 
vessel. If the salt is omitted, the effect of the water on the blood- 
corpuscles will quickly kill the patient. 

The saline fluid will become cooled before it is entirely used 
unless the vessel containing it be placed in another filled with 
fluid kept still hotter than this by frequent additions of boiling 
water. 

SUBCUTANEOUS INJECTION OF SALINE SOLUTION. 

This method is often used to gain the beneficial effects of the 
salt solution and to avoid the operation on the vein. An aspirat- 
ing needle attached to rubber tubing, which is connected with a 
bottle or rubber bag, are cleansed as described and the receptacle 
filled with the salt solution and hung above the patient. 

The needle, with the fluid running, is thrust into the connec- 
tive tissues of the thighs, lumbar region, or, in the female, beneath 
the breasts. Aseptic precautions are taken and only sterilized 
fluids used. A quart in divided portions can, by the hydrostatic 
pressure, be forced under the skin and will be quickly absorbed 



TRANSFUSION. I I I 

into the circulation. The process of absorption is hastened if the 
tissues are rubbed with the hand. A bottle or bag with two 
needles introduced at different spots will aid the introduction of 
the fluid. In an emergency a hypodermic syringe might be used 
if the customary apparatus is not within reach. 

Copious enemata of warm saline fluid carried high up into the 
colon by means of the long rectal tube are much employed in 
cases of shock from loss of blood of a lesser degree than that re- 
quiring its injection into the tissues and vessels. 

Some surgeons make it their routine practice to inject a quart 
of saline solution into the colon and leave it to be absorbed after 
rather serious operations. This, experience shows, tends to pre- 
vent shock and also the annoying thirst following anaesthesia. 

Intra- arte rial infusion has been advocated on the basis that it 
conveys the blood more equally to the heart, and so avoids excit- 
ing undue disturbance of the circulation. This method is not so 
satisfactory as the intra- venous injections and is rarely used. 

TRANSFUSION WITH BLOOD. 

While transfusion with blood is an almost obsolete procedure, 
a brief description of the technique may be of interest. 

Blood may be conveyed from one person to another either 
directly or by collecting it in a clear vessel, and after removing 
the fibrin introducing the plasma and corpuscles. From six to 
eight ounces is generally sufficient. The blood should be taken 
from a health}- , robust person, and one who is free from any con- 
stitutional or hereditary taint. The amount of blood should be 
injected slowly and with care, the effect upon the circulation and 
respiration carefully watched. If the administration causes a 
lowering of the pulse rate, or causes nervous tremors, or difficult 
breathing the flow should be stopped at once. 

The dangers of transfusion are the introduction of air, sepsis, 
blood clots and too much blood. 

Mediate Transfusion. — The donor is bled from the median 
basilic vein, the blood being caught in an aseptic receptacle, which 
stands in a basin of water at ioo° F.; the heat prevents coagula- 
tion of the blood, which may be defibrinated by whipping with a 
clean fork. The median basilic vein of the receiver is exposed by 



112 MINOR SURGERY. 

an incision, and is lifted up and opened. By the aid of an aseptic 
syringe two ounces of blood are injected into the vein of the 
patient. Two ounces more are allowed to run from the donor 
and defibrinated. This is also injected into the patient's vein, 
pressure being made between injections over the veins to prevent 
bleeding. This procedure is carried out until a sufficient amount 
is injected. 

IMMEDIATE TRANSFUSION. 

Under aseptic rules the median basilic veins are exposed for 
three-fourths of an inch in the arm of both donor and receiver. 
The veins are opened and the canulse of an Aveling syringe, 
which is filled with salt solution, are introduced. The canula in 
the vein of the donor is pushed towards the hand, that in the vein 
of the patient being pushed towards the shoulder, the arms of both 
resting upon a table. 

Constricting bands that should be placed above the site of the 
proposed injection to make the vessels more prominent are then 
loosened. Compress the tube between the donor and the bulb, 
open the stop-cock, squeeze the bulb to drive the salt solution 
into the donor, remove the pressure from the tube between the 
giver and the bulb, compress the tube between the bulb and the 
receiver, and allow the bulb to expand and fill with blood; the 
bulb is emptied inversely by the same method it was filled. 

Ten ounces of blood can be injected. 

COUNTER IRRITATION. 

A counter irritant is an agent that is used for the purpose of 
exciting external irritation. Various substances aid in the ac- 
complishment of the purpose. Their action is denoted by a mild 
hyperemia, or even a local destruction of the superficial tissues. 

Counter irritation in the milder forms is of value in the treat- 
ment of chronic inflammatory conditions, in which state it both 
relieves pain and promotes the absorption of existing exudates. 

The various means of producing counter irritation include 
rubefacients, vesicants, the seton and the actual cautery. 

Rubefacients. — Among these are hot water, Turpentine, 



COUNTER IRRITATION. 113 

Ammonia, Chloroform, Capsicum and Mustard. If applied for 
sufficient time these agents produce a vesicant action. The rube- 
facient action is really not of the greatest importance in surgical 
conditions requiring counter irritation. 

Turpentine Stupes. — These are prepared b}^ dipping hot 
flannel in warm Spirits of turpentine squeezed dry to remove the 
excess of turpentine, and then applied to the surface. This is 
covered with dry flannel and left in position for from five to ten 
minutes, and can be reapplied if necessary. Turpentine stupes 
are used in typhoid fever and peritonitis to relieve tympanites. 
In such a case the bladder function is to be watched, as absorp- 
tion of turpentine often causes strangury and retention of urine. 

Vesicants. — In this list are found Mustard, Cantharides, 
Chloroform and Ammonia. These agents cause an effusion of 
serum and lymph under the skin. 

Cantharis is used in two forms, the cerate and cantharidal 
collodion. 

The cerate may be spread upon adhesive plaster, leaving a 
margin sufficient for adhesion. It should be removed in from 
five to ten hours, and followed by a poultice. Cantharidal Col- 
lodion is a good form in which to use this agent, as it can be 
applied to irregular surfaces and not easily displaced. It is 
painted on the surface with a brush, several layers in thickness- 

Mustard is employed as a plaster made by mixing equal parts 
of the flour with flax-seed meal, to which luke warm water has 
been added to make a paste. It may also be used in the form of 
the mustard leaf, which is first dipped in warm water and ap- 
plied. In either form the mustard should be left in place for one- 
half an hour or more, and applied directly to the skin. Mustard 
is not to be recommended as a general vesicant, because it causes 
more pain than others, and the resulting ulcers are always tardy 
in healing. 

Chloroform and Ammonia. — A few drops of each upon the 
skin, over which is placed a watch-cover glass or absorbent cotton 
soaked with them, may be applied, and covered with some air-tight 
material such as oiled silk. In half an hour the needed effect is 
produced. These drugs are somewhat objectionable, as they cause 
much pain, and the resulting ulcers are often very slow in healing. 



ii4 



MINOR SURGERY. 



The Seton. — This is affected by passing a needle threaded 
with large sized silk through the affected area, the ends of the 
silk being tied together. 

After two or three days the wound is dressed, and the silk 
drawn back and forth through the wound a few times. This 
being afterwards repeated daily. The irritant effect may be in- 
creased by smearing Mercurial ointment upon the silk. 

The Actual Cautery. — To gain the desired end in the short- 
est time and the most effective manner, the actual cautery ranks 
first as a counter irritant. 

Cautery irons of various shapes and sizes have been used for 
this purpose. A general favorite is the Paquelin thermo- 
cautery. This instrument has almost altogether taken the place 
of the old cautery irons. 




Fig. 27. Paquelin Cautery. 



Its principle depends upon the power of benzine to render 
heated spongy platinum incandescent. Having heated the tip in 
an alcohol flame, the rubber bulb connected with the benzine re- 
ceiver is compressed and the benzine vapor is forced into the spongy 
platinum, which becomes heated to any degree up to white heat 
according to the pressure upon the bulb. The part to be cauter- 
ized should be cleansed and shaved. The cautery is brought to 
a white heat and is touched upon the skin in spots one -half an 
inch distant from each other or in the form of streaks parallel to 



OPERATIONS ON THE CAPILLARIES. 115 

or crossing each other. It is better to limit the burn to partial 
rather than to entire destruction of cutis. 

The counter irritant effect is greater because of the exposure 
of the ends of the sensory nerves. After cauterization has been 
produced the part can be dressed with cold compresses or a 
mixture of Olive oil, Glycerine and Succus calendula. If it is desir- 
ed to keep up the irritant effect the ulcer maybe dressed with Mer- 
curial ointment. The Paquelin cautery is of great service in 
operations for the removal of tumors where there is a generous 
vascular supply and there is a possibility of alarming hemorrhage. 
In such cases the cautery knife will cut and control hemorrhage at 
the same time. The heat of the cautery makes an aseptic wound 
which is of course an advantage. 

Ignipuncture. — By plunging a fine cautery point at a white 
heat deep into the skin and subcutaneous tissues in a number of 
places very good counter irritation is effected for deep seated 
inflammations. 

OPERATIONS ON THE CAPILLARIES. 

The capillary system of minute vessels may undergo dilatation 
and so create slowly forming and painless growths. 

The development may be limited to the capillaries of the skin, 
though the deeper vessels often are involved. These tumors vary 
in size, shape and color; a well known variety is known as 
' ' Birth-mark. ' ' This is treated according to its size and location. 
The use of red heat around the base and over the surface of the 
growth by means of the Paquelin Cautery is a very good method, 
provided the growth involves the skin alone or only the capillaries 
immediately beneath. If applied too vigorously there is a ten- 
dency to the formation of scar tissue. 

Electric needles heated to a white heat are perhaps the very 
best agent of treatment. They are thrust into the growth and 
allowed to remain for a few seconds, when the tissues will be 
fairly cooked. The needle is then carefully withdrawn and 
punctures made in other parts of the growth. The needle should 
enter the tumor or discoloration near the border rather than at 
the center of the growth. Usually five or six punctures will be 
all that is necessary. The site of the operation should be treated 



n6 



MINOR SURGERY. 



aseptically before and after the punctures, and the dressings 
should be applied so as to prevent injury or friction. 

TREATMENT BY SUBCUTANEOUS LIGATURING. 

If the foregoing method will not reduce and cure the affection, 
and especially if the growth is elevated from the surrounding in- 
tegument, treatment by ligation is indicated. 

A few methods are given below, the size and shape of the 
growth requiring one of them. 

A simple method is to thrust a needle threaded with chroma- 
tized catgut beneath the skin at the base of the growth and car- 
ried subcutaneously as far as possible around the base, and then 
passed out through the skin, to be introduced again at the point 
of exit and carried still farther around and pushed through as 
before. This is repeated until the needle is made to emerge at 
the first insertion; the ends of the ligature are then tied in a firm 
knot. 



Fig. 




Method of Applying Erichsen's ligature. 



A second method is to pass a needle with a double ligature 
through the base of the growth and then divide the catgut; each 
portion of the ligature is then carried subcutaneously around half 
of the base and tied by itself. Before tightening the ligatures 
the skin at the base of the tumor and in the line of constriction 
should be incised. 



ARTIFICIAL RESPIRATION. 117 

This puncture permits the ligature to be well fitted to the base, 
and also tends to prevent pain caused by the pressure of the con- 
stricting agents. The first method is adapted to small growths, 
while the second is more effective for larger tumors. 

A third method is applicable for growths with an elongated 
base. A double colored ligature is required and this is passed 
through the base from side to side; the white loops are then 
divided on one side and the black on another, thus forming inde- 
pendent sets of ligatures, s 

The skin is incised between the sets and tied firmly. A rub- 
ber ligature applied in a like manner is very efficacious. Dress- 
ings are not required. 

ARTIFICIAL RESPIRATION. 

This procedure is indicated where there is such impediment to 
the respiratory function that life is threatened. Foreign bodies 
in the trachea and bronchi, accidents occurring during anaesthesia, 
shocks from electricity, drowning, suffocation from any cause are 
conditions that demand the speedy performance of artificial respi- 
ration. 

Before practicing any of the recognized methods it is obvious 
that the exciting causes should be promptly removed. Foreign 
bodies of all kinds that may be causing obstruction to the ingress 
of air should be taken out by the fingers or forceps, or even by 
inversion of the patient. Mucous or liquids are to be removed 
quickly, and the clothing should be loosened about the neck, and 
if the patient be a woman corsets removed so as to allow the free 
expansion of the chest walls. Where there is a foreign body in 
the trachea or far down in the larynx and the cyanosis is alarm- 
ing, it will be necessary to open the trachea low down. 

In an emergency the wound can be held open with forceps or 
two bent hair pins or ligatures of stout silk passed through either 
side. Of course a regulation tracheotomy tube should be used if 
procurable. When this procedure is necessary the operator 
should not loose courage, if, after several minutes, there are no 
results or signs of breathing. The operator should persevere 
until he is tired, when some bystanders can be pressed into ser- 
vice. If the manipulations are kept up for a seemingly useless 



II 



MINOR SURGERY. 



length of time, often the efforts will be rewarded by the recovery 
of a patient apparently dead. In some instances the motions are 
excited for two or more hours, and then success attends the 
work. The first natural respiratory movement may be denoted 
by a gasp. The operator should not stop his efforts, but continue 
the manipulations until the breathing is natural, and the cyano- 
sis, if present, disappears. 

The temperature of the body should be strengthened by the 
application of heat applied by water bottles, hot plates or cloths 
and blankets. 

Stimulants should be given when the patient is able to swal- 
low, and also hypodermically. 

SYLVESTER'S METHOD. 

The mouth and pharynx are first cleared of mucus or foreign 
bodies, and the tongue is drawn forward with forceps or the 
fingers and secured. 




Fig. 29. Artificial Respiration, first movement. 

The patient is placed on his back upon a table or other firm, 
smooth surface, a pad is placed beneath the shoulders and the 
body partially inverted by raising the foot of the table. The 
operator stands or kneels at the patient's head. 

First movement (inspiration) : Grasp arms at or just below the 
elbows. Bring the arms up over the head and down so that the 
elbows are on a level. Hold them there for three seconds, or 
while counting one, two, three rather slowly. The muscles at- 
tached to the humerus and to the ribs pull upon the latter so as 
to expand the chest and air enters the lungs. 

Second movement (expiration) : From this position carry arms 
down so that the elbows rest upon either side of the front of the 
chest. L,et the weight of your body bear upon the chest and ribs 



ARTIFICIAL RESPIRATION. 119 

while counting one, two, three rather slowly as if you were en- 
deavoring to squeeze the air out of the lungs, which is in fact 
precisely what should be done. If this plan is regularly carried 
out it will make about sixteen complete acts of respirations in a 
minute. It should be kept up for a long time and not abandoned 
until all hope of saving the patient is exhausted. The absence 
of the pulse beat at the wrist amounts to nothing as a sign of 




Fig. 30. Artificial Respiration, second movement. 

death, and often life is present when only a most acute and prac- 
ticed ear can detect the sound of the heart. In a moderately 
thin person deep pressure with the finger ends just below the 
lower end of the sternum may sometimes reveal pulsation in the 
aorta, when it cannot be found anywhere else. 

As soon as natural respiration begins to be attempted, it should 
be aided as much as possible by timing the artificial to it. 

LABORDE'S METHOD OF ARTIFICIAL RESPIRATION. 

Professor Laborde, of Paris, has promulgated a new theory of 
resuscitation in cases of asphyxia from drowning or any other 
cause and in electric shock. 

The tongue of the patient is grasped firmly by two fingers, 
covered with gauze or handkerchief, and stretched at regular 
intervals of about every ten seconds, and then relaxing it without 
letting it go. Now and then the process should be stopped in 
order to ascertain whether breathing has begun again. In a 
great number of cases after a few of these stretchings of the 
tongue a spasmodic inspiration occurs. If a second one seems 
inclined to follow or does occur, the aim should be to have a suc- 
ceeding pull coincide with the next respiration, and so on until 



120 MINOR SURGERY. 

respiration seems to be able to go on of its own accord. This 
method is simple and easy to apply. Of course the nose and 
mouth should be first cleared of mucus or foreign bodies. It is 
important to follow out the procedure for half an hour or hour, 
unless the case is really hopeless. 

Laborde's method of resuscitating the apparantly dead has been 
well tried in still born children. The tongue at first will give no 
resistance; after a while it resists positively, soon very mild re- 
piratory movement is noticed, then all is quiet. In a short time 
the breathing is stronger and has a normal character and the child 
begins to cry, move, etc. 

If the patient is put in a hot bath the stimulus thus provided 
is an aid. 

MOUTH TO MOUTH INFLATION. 

This method of assisting the respiratory function is only neces- 
sary in grave emergencies and more especially in the case of very 
young children. 

The physician or layman first draws the tongue f oward with the 
fingers of one hand, closes the nostrils with the other and then 
applies his mouth directly to the patient's. Then by a strong ex- 
piratory movement aims to force air into the chest. If this is un- 
successful pressure is then made upon the chest walls to expel the 
air from the lungs. This method ought to be repeated about 18 
times to the minute. The same object can be accomplished with 
the aid of a rubber catheter which is lubricated and passed into 
the trachea through the mouth and the lungs expanded by air 
blown through the tube. The catheter can be passed through 
the nose if the teeth are clenched. 

HOWARD'S METHOD. 

This method is the one practiced by the life saving crews and 
is described as follows : 

( i ) Instantly turn patient downwards, with a firm roll of cloth- 
ing under stomach and chest. Place one of his arms under his 
forehead, so as to keep his mouth off the ground. Press with all 
your weight two or three times, for four or five seconds each time, 



ARTIFICIAL RESPIRATION. 121 

upon patient's back, so that the water is pressed out of lungs and 
stomach and drains freely out of mouth. 

(2) Then quickly turn patient face upward, with roll of cloth- 
ing under back just below shoulder blades, and make the head 
hang back as low as possible. Place patient's hands above his 
head, kneel with patient's hips between your knees and fix your 
elbows firmly against your hips. 

Now, grasping the lower part of the patient's naked chest, 
squeeze his two sides together, pressing gradually forward with 
all your weight for three seconds, until your mouth is over the 
mouth of the patient; then with a push suddenly jerk yourself 
back. Rest about three seconds; then begin again, repeat- 
ing these bellows blowing movements with perfect regularity, 
so that foul air may be pressed out and pure air be drawn into the 
lungs, about eight or ten times a minute, for at least one hour or 
until patient breathes naturally. 

FEEL'S METHOD. 

Forced respiration is best effected by means of a bellows after 
the method of Dr. George E. Fell. By its use air can be forced 
into the lungs either directly through the mouth and larynx or 
through a tracheotomy tube. The writer has been with the 
originator of this method in the Buffalo hospitals, and cannot 
speak too highly of the most excellent results attained. 

The air is given through a mask that is applied over the face 
and attached by rubber tubing to a bellows that are worked by 
an assistant. 

TREATMENT OF THE APPARENTLY DROWNED. 

Just how long a person may be immersed without destroying 
life cannot be accurately determined. Immersion even for one 
minute causes death, while pearl fishers and sponge divers remain 
under water for three and four minutes, having acquired such 
ability by practice. There are two classes of cases met with; in 
the first as soon as the person falls into the water a condition 
which resembles fainting ensues, probably due to the shock. 
The heart beats very feebly. The breathing stops and no water 






122 MINOR SURGERY. 

is drawn into the lungs. Restoration to life is more probable 
than in the second kind, where fainting does not occur, and in an 
attempt to breathe while immersed water is drawn into the air 
passages. 




Fig. 31. The Fell-O'Dv^er Apparatus Used in Artificial Respiration. 

The following rules have been recommended to be followed in 
the apparently drowned: 

It is important that the wet clothing should be removed as soon 
as possible from the patient. This can always be done without 
interrupting the artificial respiration. Exposure of the person 
can be avoided by covering the body by a coat, shawl, a sail or 
blanket. 

As the patient is suffering from loss of heat, warmth is to be 
secured b} r the use of hot bottles, plates, bricks, stones or even 
boards that have lain in the summer sun. The bod}^ and limbs 
may be gently but constantly rubbed toward the heart to help the 



SUFFOCATION FROM GAS. 1 23 

blood in its labored circulation. None of these things need inter- 
fere with the efforts to secure respiration, which must be uninter- 
rupted except for an occasional pause to see whether the patient 
is himself attempting to breathe. Change of color in the face, 
gasping or movement of the pit of the stomach are favorable 
signs. Some stimulant is to be given as soon as it can be swal- 
lowed. Teaspoonful doses of whisky or brandy in a teaspoonful 
of hot water may be given every few minutes. Slap the bare 
chest with a towel wet in s cold water, or better apply hot and cold 
water alternately on the chest. Where it is available there is no 
stimulus to respiration better than that of a good Faradic battery 
used so as to cause deep breathing by the pain it causes. Little 
by little natural breathing will take the place of the artificial, but 
must not be left unwatched for some time. After resuscitation 
the person should be put in a warm bed, being carefully carried 
with the head low, and watched to see that the breathing does 
not suddenly stop. Hypodermic injections of Brandy, Nitro- 
glycerine, Strychnine or Digitalis may then be given. 

SUFFOCATION FROM GAS AND VAPORS. 

This is usually caused by the ordinary illuminating gas, car- 
bonic acid gas, fumes of charcoal and the collections in mines, 
wells and cesspools. In these cases the patient is suffering not 
only from want of oxygen, but from poisoning of the blood pro- 
duced by the absorption of gas. 

The treatment consists of giving plenty of fresh air. Open all 
doors and raise or break windows from the outside is possible; if 
not, open the door and the mouth and nose of the rescuer should 
be covered with a towel wet with water. The nearest window 
should be broken open or raised, and remove the patient to fresh 
air. 

If the patient is breathing slap the chest with cold towels or 
pour hot and cold water alternately on the bare chest. If the 
patient is breathing faintly artificial respiration should be per- 
formed and other described details carried out. The removal of 
a person from a well full of poisonous gas is a difficult and delicate 
matter. Some attempts may be made to dislodge or dissipate the 
gas. Buckets of water may be dashed down or an umbrella low- 



124 MINOR SURGERY. 

ered by the handle and rapidly drawn up a number of times. 
But these efforts must not consume any more time than is required 
to prepare a man who can be lowered securely fastened to a rope, 
so that he can attach another rope to the person overcome in the 
well. 

The success of the attempt will depend on the rapidity of the 
work of the rescuer. 

RESUSCITATION AFTER SUFFOCATION, CHLORO- 
FORM POISONING AND ELECTRIC SHOCK. 

Prus arrived at the theoretic conclusion that healthy human 
beings who were suddenly apparently killed by asphyxiation, 
electricity, chloroform, or other poisons, could be resuscitated by 
artificially imitating the conditions in which higher organisms 
are accustomed to live. These conditions can be simulated by 
artificial respiration and by an artificial circulation of blood. 
The former may be accomplished by the various well-known 
methods, while Prus found in his experiments that the circula- 
tion can be artificially stimulated most closely and most certainly 
by rhythmic pressure of the finger upon the exposed heart, for 
only in this way is it possible to evoke a systole and diastole of 
the heart. By experiment, the author proved that this theory 
works in practice. He was able to resuscitate animals after suf- 
focation after a,n apparent death by means of massage of the ex- 
posed heart, artificial respiration, and an infusion of normal salt 
solution into the femoral artery. Seventy per cent, of his experi- 
ments were successful. Of twenty-one experiments with animals 
in which the pulse and respiration were stopped by chloroform, 
the author successfully resuscitated sixteen, or seventy -six per 
cent. In some instances an hour had elapsed from the moment 
of death to the time of beginning the massage of the exposed 
heart. 

SUNSTROKE AND HEATSTROKE. 

These terms are applied to certain symptoms resulting from the 
exposure to excessive heat of the whole or parts of the system, 
while the latter is in a debilitated condition and resulting from 



SUNSTROKE AND HEATSTROKE. 1 25 

intoxication due to metabolic changes. Excessive heat in any 
form is the main cause, whether it be exposure to the sun's rays 
or the undue heat of a boiler room or laundry. Exercise also 
causes heat strokes. 

Treatment. — The patient should be at once removed to a cool 
and shad}^ place, placed in a recumbent position, the head slightly 
elevated. The chest and shoulders are stripped of clothing and 
douched with cold water. Cold applications are applied to the 
head. Stimulants may be given as required. The ice pack and 
ice cap are useful, and ice water dashed with force from dippers 
at distances of from eight to ten feet for half an hour, if neces- 
sary, against the entire naked body. An eifective stimulant is a 
fine stream of ice water poured from an elevation upon the fore- 
head for a minute or two at a time. When the temperature falls 
to 102 degrees the cold applications can be safely discontinued, 
and the patient wrapped dry and put in bed. At one of the New 
York hospitals the following method of treatment is used: 

The ambulances are kept supplied with ice, which is packed 
about the patient's head from the moment he is picked up until 
he enters the hospital. The patient is then stripped, the tem- 
perature taken per rectum, while the individual is placed upon a 
table and covered with a sheet, upon which are placed small 
pieces of ice. An ice cap is applied and ice water is dashed upon 
the body. The temperature is carefully taken, and when it 
reaches 103 F. the patient is placed in bed, covered with blankets 
and hot water bottles are placed about him. Care is taken not to 
reduce the temperature to 99 or ioo° F. by the ice applications, 
as it ma}^ continue falling, become subnormal and leave the 
patient in collapse. Strychnine should not be given, as it seems 
to cause convulsions. If these occur Chloroform by inhalation 
will control them. Hypodermics of whisky or brandy are used 
in extreme cases. If there is a secondary rise of temperature the 
entire treatment will have to be repeated until the temperature 
falls. It is advisable to continue the ice bag to the cranium 
while the patient is in the hospital, or is dismissed from further 
treatment. Artificial respiration is indicated where there are 
signs of respiratory failure. The after treatment consists of light 
but nourishing diet, fresh air, the ice cap and stimulants when 
necessary. 



126 MINOR SURGERY. 



FROST BITES. 



The constitutional and local effects of intense cold upon the 
system are very similar to the results produced by exposure to 
extreme heat. If the tissues are subjected sufficiently long to 
arrest the circulation, there will be constitutional symptoms con- 
sisting of slow pulse, labored respiration, subnormal temperature, 
dilatation of the pupil and drowsiness. Frequently the patient 
will be so drowsy that he is irresistibly tempted to lie down and 
sleep to certain death. The local effects may be divided, as are 
burns, i. <?., first, second and third degree frost bites. In the first 
degree the skin is of a dusky hue, and there is some oedema. 
The skin becomes more painful if heat is applied, though usually 
only itching is noted. If pressure is made with the finger over 
the swollen tissues a white spot results. This slowly turns red, 
denoting a disturbance of circulation. Chilblains or perino are 
common terms used to describe this condition. 

In the second degree the color changes to a deeper hue, and 
may have rather a bluish, mottled tint and vesicles form. They 
tend to break and indolent ulcers result. As a rule, frost bites of 
the second degree are more tardy in healing than burns of the 
same extent. In the third degree the tissues are bloodless in 
appearance or dark blue, are insensible to touch, and the frozen 
parts covered with vesicles. Gangrene soon makes an appear- 
ance, which is not infrequently followed by a local or general 
septic condition. 

Treatment. — When a considerable portion of the body is 
frozen one should not make the mistake of applying heat in any 
form at the beginning of the treatment. The point to be 
observed is the gradual application of heat, and this is accom- 
plished by placing the patient in a cold room, rubbing him with 
a sponge soaked in cold water or handfuls of snow and ice. The 
patient may also be put in a cold bath (6o° F.), the temperature 
of which is gradually raised to 90 in the next three hours. 
Hypodermic injections of Strychnia, Nitroglycerine or Brandy 
may be given, or drugs can be administered in cold water when 
the patient can swallow. Severe pain can be somewhat lessened 
by putting on ice cold cloths or ice bags. Artificial respiration is 



POST-OPERATIVE INSANITY. I 27 

indicated, and should be practiced for a long time even if the 
individual be apparently dead. If the extremities are involved 
they should be elevated early and rubbed briskly towards the 
body. 

The local treatment has for its object the gradual application 
of warmth. Handfuls of snow and ice should be thoroughly 
rubbed on the parts and followed by warmer applications. The 
vesicles should be pricked with an aseptic needle and if ulcers 
occur the condition is treated exactly as a burn of similar degree. 
Should gangrene supervene antiseptic measures must be most 
carefully observed. Amputation is frequently necessary to save 
life. Should phlegmonous cellulitis occur it requires multiple 
and deep incisions, irrigation with bichloride of mercury solution 
1 to 2000, and drainage provided. Moist dressings are required. 
The treatment of chilblains requires freedom from pressure due to 
tight fitting shoes, keeping the parts warm and dry and the 
application of either of the following: Tincture of iodine; Car- 
bolic acid, 1 to 10; Nitrate of silver, i to 40; Menthol; Oil of pepper- 
mint; Ammonia; Chloroform liniment and a 20 per cent, solution 
of Ichthyol in Glycerine. We have found Thiol, an Ichthyol com- 
pound, an excellent application for slight frost bites and chilblains. 
Pulsatilla is indicated for chilblains if there is much swelling or 
itching. Suph. if the chilblain is of long standing. 

POST-OPERATIVE INSANITY. 

Mental aberration following surgical operations has been often 
noted though the general adoption of aseptic methods has 
lessened the number of cases. Slight cases have been termed 
traumatic or nervous delirium. Others have become more or less 
insane. Baldy's experience led him to the following conclusions: 

1 . Cases of serious mental derangement may occur after opera- 
tions on patients without any previous personal or family his- 
tories of insanity: 

2. Mental disorders are no more likely to follow operations on 
the sexual organs than on any other part of the body. 

3. Such disorders occur just as frequently in men as in women. 

4. Operations are at times the determining cause of mental de- 
rangements where there was no previous tendency to the disease. 



128 MINOR SURGERY. 

5. Mental disturbances occuring a considerable time (months) 
after an operation are most probably independent of the surgical 
procedure. 

6. The development of the psychoses may follow in those cases 
in which the convalescence from the operation has been perfect. 

7. The existence of a predisposition to psychoses should stay 
the surgeon's hand, except in such cases as are urgent and neces- 
sary. 

8. Mental derangements follow operative procedures with more 
frequency than is generally supposed. 

Treatment. — Strict attention to aseptic details during the 
operation will tend to prevent this complication. The patient 
should be well nourished and all sources of irritation — both physi- 
cal and psychical — must be sought for and removed. The drugs 
most likely to relieve the acute mania are Belladonna, Hyoscyamus 
and Stramonium. 

REMOVAL OF TATTOO-MARKS. 

Tattoo-marks are the result of the introduction beneath the skin 
of India ink by special needles. The technique of their removal 
is as follows: 

Make a mass the consistency of dough, with Salicylic acid and 
Glycerine; apply to the marks and confine with a gauze compress 
and strips of rubber adhesive plaster for six days. Remove the 
layer of epidermis over the marks, and apply Salicylic acid and 
Glycerine again. Usually the second application removes the 
tattoo-marks, though in some cases a third treatment will be re- 
quired. 

When more energetic measures are required the technique of 
a St. I^ouis physician may be carried out. The tattooed skin 
is shaved and made surgically clean. The skin is anaesthetized 
with a spray of Chloride of ethyl. Then the surface, which is 
tattooed, is covered with caroid solvent. Next in order is to take 
a bunch of needles, previously prepared and rendered aseptic, 
and dip them in the caroid solvent, driving them in the tattooed 
part with a sharp blow. This is repeated several times over the 
entire tattooed skin. Much of the success obtained depends upon 
the proper preparation of the bunch of needles. The best method is 



MORPHINE IN SURGICAL PRACTICE. 1 29 

to get some shoe-maker's wax, melt it, and as it is about to harden 
put in a number of fine cambric needles so that they will have 
about half an inch free, the points being upon the same level. 
Milliner's needles, No. 9 and 10, will serve the purpose admirably. 
This curative tattooing must be thorough to insure good results, 
and yet the needles must not be driven so deeply as to draw any 
but least quantity of blood. After this tattooing has been done 
the caroid solvent is poured over the area worked on and covered 
with two or three layers of gauze, previously soaked in the solvent. 
In a few days, two or three, when the latter is removed, the tat- 
too-marks present a hazy, light appearance. Very shortly after 
some crusts appear, and when these fall off traces of the tattoo- 
ing will be gone. If the least bit should remain the process is to 
be repeated. As a general rule, it is necessary to repeat the pro- 
cedure to obtain the best results. 

MORPHINE IN SURGICAL PRACTICE. 

According to Martin the general indications as to the employ- 
ment of Morphine in surgery may be summarized as follows: 

1. Morphine should be given hypodermically and in doses 
sufficient to accomplish the purpose for which it is given. 

2. When surgical shock is attended by such severe pain as to 
cause uncontrollable restlessness, Morphine should be given in 
doses adequate to relieve it. The same treatment is indicated for 
shock-restlessness without pain (usually due to hemorrhage), the 
appropriate general treatment for shock being also carried out. 

3. Morphine is the best internal haemostatic in the treatment 
of hemorrhage. When the hemorrhage is complicated by rest- 
lessness Morphine is absolutely indicated, because of its quieting 
effect upon both mind and body. 

4. When drunkards, or exceptionally neurotic patients, are to 
be anaesthetized, a preliminary hypodermic injection of Morphine 
renders such anaesthetization quicker, easier and safer, and favor- 
ably affects the stage of recovery. Obstinate and exhausting 
vomiting after Ether is sometimes relieved by Morphine. 

5. If in the first twenty-four hours after operation pain be- 
comes so severe as to cause uncontrollable restlessness, this pain 
should be relieved by Morphine. To this rule there are practi- 

9 



130 MINOR SURGERY. 

cally no exceptions; it applies to all operations regardless of the 
operative area. 

6. When used in accordance with these indications the benefi- 
cial effects of Morphine so overshadow its injurious effects that 
the latter are not demonstrable. To this rule there may be a 
very few exceptions. 

FOREIGN BODIES IN THE TISSUES. 

Foreign bodies are often forcibly injected under the skin and 
into the deeper tissues. If aseptic at the time the object may be- 
come encysted, or it may set up a suppurative process as a result 
of infection. If the presence of the foreign body causes severe 
pain or endangers the patient on account of the locality involved 
it should be removed as soon as possible. The location of certain 
foreign bodies can be definitely determined b}^ the use of the 
X-ray, and incision made accordingly. Cocaine or Eucaine in 
two per cent, solution injected into the tissues take the place of a 
general anaesthetic fairly well, and allow all manipulations to be 
made almost painless. When the operation is on an extremity 
the use of a rubber constricting band is indicated, so that the 
operative field will not be obscured by blood. The incision should 
be made at an angle with the supposed direction of the long axis 
of the foreign object and not as it is so often done parallel with 
it. If the body be a needle the incision should be made slightly 
above the point of entrance, as needles have a tendency to migrate 
rapidly through the tissues. The edges of the wound are held 
apart by retractors and the dissection made as deeply as necessary. 
At different times the carefully disinfected finger is introduced to 
palpate the parts if the object cannot be seen or distinctly felt. 
The volar surface of the finger imparts the clearer sensation, as 
one ma}^ be deceived by the contact of the end of the finger or finger 
nail with tense fibres which may feel exactly like the foreign 
body. The end of a knife handle is often useful in the search 
for the object wanted. If the body is found it may be withdrawn 
by forceps and a moist dressing applied after the introduction of 
necessary sutures. Silicea given internally is said to aid in the 
expulsion of foreign bodies from the tissues. 



UNCONSCIOUSNESS. 131 



UNCONSCIOUSNESS. 



It is at times difficult, when a person is found unconscious, to 
determine the real cause of the condition. It is of much import- 
ance, however, since upon the diagnosis must depend the treat- 
ment of the patient. Among the chief causes of sudden loss of 
consciousness are syncope, cerebral hemorrhage, Bright 's disease, 
diabetes, drunkenness, injury to the head and epilepsy. 

In syncope the condition is recognized by the pale face, weak 
pulse, complete or partial loss of consciousness. The attack is 
sudden. The patient should be placed flat on the back without 
elevating the head. All tight clothing should be loosened. 
Fresh air is necessary, and the face may be sprinkled with cold 
water. Smelling salts, heat and friction aid. If the coma per- 
sists heart stimulants are indicated, and brandy or strychnia may 
be given hypodermically. 

In cerebral hemorrhage the respiration is rather slow, with 
loud snoring, with blowing out of the lips and one cheek. The 
pulse is full and slow. Hemiplegia is likely to be present, and 
the pupils of the eyes uneven in size. Such cases must not be 
moved unnecessarily, but should be placed in a quiet darkened 
room and turned on the paralyzed side. Bandages should be 
loosely tied about the extremities to obstruct the venous flow. 
Hypodermic injections of morphine will be necessary if the 
patient throws himself about upon the bed. 

In unconsciousness resulting from Bright' s disease the breath- 
ing is more rapid and not noisy, and in the condition due to 
diabetes the inspiration is slow and prolonged, with a short and 
quick expiration. 

Fracture of the skull should always be suspected in cases of 
head injuries. The eyes, ears and nose should be examined. If 
there is hemorrhage from the ears there is a possible fracture of 
the base of the skull; hemorrhage from the nose or into the eyes 
or eyelids suggests a fracture of the orbit or facial bones. The 
scalp need not be broken and still there may be a fracture of the 
skull. Aseptic dressings should be applied to scalp wounds if 
present, while the ears and nostrils should be plugged with clean 



132 MINOR SURGKRY. 

gauze or cotton to prevent infection by these channels. Sub- 
sequent treatment may require operative measures. 

In epilepsy the patient may cry out and fall to the ground in a 
spasm. He may throw himself about violently, froth at the lips, 
and attempt to bite the tongue or lips. A piece of stick, knife 
handle or rolled handkerchief should be inserted between the 
teeth, and the patient's limbs judiciously controlled. Smelling 
salts, inhalations of ammonia or amyl nitrite aid in the recovery 
from the attack, 

In opium poisoning the unconsciousness is usually complete. 
Note should be taken of the respiratory function. If it is very 
slow, six or eight or less in a minute, and there is stertorous 
breathing, pupils greatly contracted or widely dilated, face puffed 
and dark red in appearance, pulse full and labored or slow and 
feeble, and the coma is profound, the probability is that the case 
is one of opium poisoning. 

A drunken man may often be slightly aroused if spoken to in 
a loud voice, pricked with a pin or rapped on the soles of the feet 
with a stick. It is not safe to assume that a man is drunk simply 
because the breath smells of alcohol. The physician should not 
decide that such is the case without corroborative evidence. A 
man may have been only slightly under the influence of liquor, 
and in that condition he may have received a blow on the head, 
or have had a stroke of apoplexy. Very often an over-anxious 
bystander has poured whiskey down his throat with the mistaken 
idea of giving relief. 

SIGNS OF DEATH. 

The following have been suggested as methods of deciding 
whether death has occurred: 

1. Tie a string firmly about the finger. If the end of the 
finger becomes swollen and red life is not extinct. 

2. Insert a bright steel needle into the flesh. If it tarnishes 
by oxidation in the course of half an hour, life may be considered 
not extinct. 

3. Inject a few drops of I^iquore ammonise under the skin. 
During life a deep red or purple spot is formed. 



PLASTERS AND POULTICES. 1 33 

4. Moisten the eye with Atropine. During life the pupil will 
dilate. 

5. Look at a bright light or at the sun through the fingers 
held closely side by side. During life the color is pink, after 
death a dead white. 

6. After death a dark spot is said to form gradually on the 
outer side of the white of the eye, from drying of the sclerotic, 
so that the dark choroid shows through. 

7. Putrefaction is an absolute sign of death. Better delay for 
it than run any risk of burying alive. 

PLASTERS AND POULTICES. 

Different varieties of plasters are found useful in various ways 
in surgical procedures. Plasters are used to hold dressings in 
position, to cover small incisions, such as are made in sub-cutane- 
ous operations, for making extension dressings for the treatment 
of fractures, for strapping the chest in fracture of the ribs and 
sternum, for strapping the pelvis, fractures of the pelvic bones 
and for making uniform compression in inflammatory conditions 
of the breast and testicle, to support joints and in the dressing of 
ulcers. 

Before using any form .of plaster extensively the hairy parts 
should be shaved, because of the pain that will ensue due to trac- 
tion in case of extension being used, and pain being caused when 
it is removed. The parts should be wiped off with alcohol before 
applying plaster. 

Rubber adhesive plaster is very commonly used. It is irritat- 
ing to certain individuals. This plaster is made by spreading a 
preparation of India rubber on muslin, and can be applied with- 
out being previously heated. Rubber plaster can be easily pro- 
cured from any pharmacist, and is a favorite plaster. It can be 
sterilized if necessary by passing the unspread side rapidly 
through the flame of an alcohol lamp. The dermatitis often 
resulting from the application of plasters is easily treated by 
alcohol or dressing powder. Rubber adhesive plaster is prepared 
on rolls of various sizes. 

Resin Plaster. — This plaster is one of the favorite plasters 



134 MINOR SURGERY. 

for surgical dressings. It is a good substitute for the rubber 
plaster, for it does not irritate trie skin, and if a plaster has to be 
applied for some time it is perhaps the best. Resin plaster is 
heated before applied and then takes hold strongly. 

Soap Piaster. — This plaster is employed to protect bony 
prominences from pressure. It is very useful to prevent the 
formation of bedsores. It is prepared by speading certain forms 
of soap on soft leather, such as kid or chamois. 

Poui/riCES. — The varieties of poultices which are most com- 
monly employed are the flaxseed, soap poultice and starch poul- 
tice. Poultices have been much used in the past in the treatment 
of inflammatory conditions, though now antiseptic compresses 
have largely taken their place. A poultice must be put on hot. 
To secure this it may be spread over a hot plate; care must, how- 
ever, be taken not to put on a poultice so hot as to burn. To 
keep a poultice hot when applied it should be covered with oiled 
silk or several folds of bandage. It is imperative in the chang- 
ing of a poultice to have the hot poultice ready to apply imme- 
diately after taking off the first one. 

Flaxseed Poultice. — This poultice is made by adding to 
ground flaxseed a little cold water, and then boiling and stirring 
it until a rather thick mixture results. A piece of muslin, a little 
larger than the intended poultice, is spread evenly with the poul- 
tice mixture from % to % inch in thickness. A margin of one 
inch is left which is turned over after the poultice is spread, and 
will prevent it from escaping around the edges when applied. 
The surface of the poultice may be covered with a little olive oil 
or white of egg to prevent the mass from adhering to the skin 
upon drying. Two ounces of fine cut tobacco incorporated with 
the flaxseed and boiled makes an effective poultice when a nar- 
cotic is necessary. This mixture is very useful for reducing in- 
flammation in orchitis and epididymitis. Equal parts of ground 
charcoal and ground flaxseed may be used as an application to 
gangrenous parts to hasten their separation and to diminish the 
odor arising from the necrosed tissues. 

Soap Poultice. — The removal of thick and hardened epider- 
mis is facilitated by the application of a soap poultice to the parts 
the night before, or a few hours before an operation. A soap 



PLASTERS AND POULTICES. 1 35 

poultice is made by soaking a number of layers of gauze in a 
mixture of one part green soap and six parts water. It is then 
applied covered with oiled silk or waxed paper. 

Antiseptic Poultice. — This is useful where the skin is 
broken, and the effect of a poultice is needed without the liability 
to cause infection. A pad of sterile gauze wrung out of hot 
bichloride solution applied to the part and then covered with 
oiled silk forms an antiseptic poultice. If there is considerable 
lesion of the soft parts the bichloride solution should not be kept 
on long enough to cause constitutional symptoms due to absorp- 
tion of the mercury. 

Hot compresses are used to keep up the vitality of the parts that 
have been injured. The crushing of tissues in various ways will 
devitalize them to such an extent that necroses will often be the 
result. 

Hot fomentations are successfully used to combat inflammatory 
conditions of the eye. Pads of gauze wrung out of hot water, 
which has been boiled, are placed over the part, covered with 
oiled silk and bandaged. Other pads should be placed in hot 
water and be applied when the first pad begins to cool. This is 
kept up constantly, sometimes for hours or days, until the tissues 
resemble their normal appearance or the inflammation has sub- 
sided. 

Cold compresses are prepared and applied in the same manner, 
and can be used to combat inflammation. 

Ice bags are used for similar purposes as cold compresses. 
These are especially fitted for inflammatory conditions of the 
joints and cranium, and are used by some to apply to the abdo- 
men in appendicitis and peritonitis, and to control internal hem- 
orrhage. Before using the ice bag the part should be covered 
with a towel or two, as it makes the dressing more comfortable 
to the patient. 

Anti-phlogistine, Anti-thermoline and Pyroeistine. — 
These are proprietary mixtures that have much claimed for them 
in the way of causing the condition known as osmosis. The 
agents are said to reduce inflammation by abstracting effusions 
from the tissues, and are used in treating peritonitis pleurisy, 
pneumonia, inflammation of joints, carbuncles, etc. They are a 



136 



MINOR SURGERY. 



clay-like mass, medicated, and are applied to the surface after be- 
ing spread on absorbent cotton. We have had good success in 
treating some inflammatory knee-joint cases with these agents. 

NEEDLES AND SUTURES. 

The materials most often employed for the purpose of suturing 
at the present time are catgut, silk, silver wire, horse hair, silk- 
worm gut, kangaroo tendon. A variety of materials have been 
introduced with advantages claimed for each, though experience 
teaches that well prepared chromatized catgut and silk are the 
most reliable and more widely used for sutures. Sutures are 




Fig. 32. Hagedotn's needles. 

introduced by means of surgical needles, which are of various 
shapes and sizes. Some needles for use in special cases are 
mounted on handles, while the use of one of the regular needle 
holders facilitates the introduction of a needle in suturing. A 
pair of haemostatic forceps will hold the needle securely if the 
needle holder is not at hand. 




Fig. 33. Method of tying square knot. 

Method of Securing Sutures and Ligatures. — The square 



NEEDLES AND SUTURES. 



137 



or reef knot is employed in tying a blood-vessel. The ligature 
material is held in the palm of the right hand between the thumb 
and finger; the end is then thrown around the forceps closely and 




Fig. 34. Reef knot 



caught with the left hand, and carried across the right thumb 
and inserted between the third and fourth fingers of the right 
hand. The left at the same moment seizes the other end, and 
the ends of the threads are drawn out. There will now be no 
difficulty in drawing the knot thus formed tight with the fore- 
fingers or the thumbs. To complete the knot by making another 
tie the same maneuver is to be effected, taking care always to 
begin with the opposite hand to that which began before. It is 
immaterial which hand begins the first part of the knot so long as 
the opposite hand always begins the second part. After tighten- 
ing the first fold of the knot care should be taken not to disturb 
it by making the ends tense during the tying of the second part, 
for if the first part be then loosened unnoticed the knot will be 
insecure and ineffective. Students should practice the tying of 
this knot in order to not confound this with the " Granny knot," 
which knot slips easily and should not be used. 




Fig. 35. Method of tying granny knot. 



Surgeons' or Friction Knot. — This knot is formed by mak- 
ing two turns of the ligature at the first loop instead of one, or in 
other words, it is formed by carrying one end of the thread twice 



I38 MINOR SURGERY. 

around the other. This knot will not slip if tied tightly, and is 
especially effective for tying a blood vessel, as the reef or square 
knot has a tendency to relax, and thus we have an imperfect 
closure of the vessel. 




Fig. 36. Method of tying surgeons' knot. 

The Staffordshire Knot. — This is used in tying off pedi- 
cles, and is formed by carrying the ligature through the pedicle 
and returning the needle so as to leave a loop at the farther side. 
The loop is then slipped over the pedicle and the free ends are 
carried one above it and the other below, where the two are 
united with a reef knot. 

THE DIFFERENT FORMS OF SUTURE. 

The continuous, interrupted, quilled, twisted or harelip, button, 
relaxation and coaption sutures are the forms generally applied 
for the ordinary purposes of suturing. 

Thk Continuous Suture. — This suture aids in the union of 
superficial wounds and such others as require but little force to 
cause a proper adjustment of the divided surfaces. It is made by 
repeatedly passing the needle through the tissues without cutting 
the thread, and after fitting the sutures to the wound strain 
completing the union and confining the end of the thread by 




Fig. 37. Continuous suture. 

means of a final suture formed by uniting the ends caused by 
division, close to the eye of the needle, with the end of the suture 
remaining at the opposite side of the wound. 



THE DIFFERENT FORMS OF SUTURE. 



139 



The Interrupted Suture. — This suture is made by passing 
a needle and material through the skin and deeper borders of the 
wound at such a distance from them as the size and depth of the 
wound demands. The suture is then tied by a reef knot drawn 
with only sufficient force to approximate the borders without 
wrinkling them. The knots can be placed at alternate sides of 
the wound, or on one side only. If there is possible tension 
alternating deeper sutures may be placed. Superficial sutures to 
oppose the borders can be introduced between deeper ones. 





Fig. 38. The interrupted suture. 

The Quilled Suture. — This suture is formed by passing 
several doubled threads through the lips of the wound one-half or 
one inch or more apart, and uniting them over pieces of wood, 
quills or rubber tubes, as these lie parallel with the incision. 
This suture is useful in closing deep gaping wounds where the 
tension is great, and in large cavities lined with mucous membrane. 




J HA I 



Fig. 39. The quilled suture. 

The Twisted or Harelip Suture. — This is made by push- 
ing a harelip pin through the edges of the wound and passing 
aseptic silk or narrow strands of aseptic gauze around the pin in 



I40 MINOR SURGERY. 

a continuous or interrupted figure of eight form, thus bringing 
into close approximation the divided surfaces of the wound. 
The materials used to oppose the edges should be changed often 
if soiled. Ordinary pins or needles can be used if the harelip pin 
be not available. The spaces intervening between the pins can 
be closed with superficial interrupted sutures if necessary. 
This suture is of much value in closing deep wounds. 




Fig. 40. The twisted suture. 

The, Button Suture. — This suture is indicated where there is 
considerable tension of the parts, and like the quilled suture, aids 
in the union of the deep portions of the wound, thereby relaxing 
its borders and so allowing them to be united with simple sutures, 
which are not exposed to traction. A needle with a double 
thread is passed like a quilled suture, the ends of the suture be- 
ing passed through the eyes of a button before being threaded in 
the eye of a needle. After the suture, prepared in this way, has 
been passed through both sides of the wound, the needle is 
removed and the free ends of the suture are passed through the 
eyes of the button on the opposite side and are drawn taut and 
tied. 



Fig. 41. Button suture. 

The Buried Suture. — Buried sutures are employed to close 
in dead spaces in the wound and to suture the different layers of 
tissues that form its walls. Catgut, silk and silver wire are em- 
ployed for the purpose. While buried sutures close in the dead 



THE DIFFERENT FORMS OF SUTURE. 



141 



spaces and so prevent a possible wound infection, there is the dis- 
advantage of the introduction into the wound of a foreign material 
which may cause infection. 





Fig. 42. Ford's suture. A square knot. 

A single knot. A double or friction 

knot, and the first method of 

passing the needle to tie a 

single knot immediately. 



Fig. 43. Ford's suture. Showing two 

square knots, a single knot, and 

the method of completing a 

square knot. 



The Subcuticular Suture. — The needle, armed with fine 
catgut or silk, is introduced at the under surface of the skin at 
one side and passed out just beneath the cut edge; it is then 
passed in the reverse direction at the opposite side and tied. The 
use of the subcuticular stitch is recommended to avoid the possi- 
bility of infection by the skin coccus that often causes the so- 
called ' ' stitch abscess ' ' when the suture is passed through the 
skin. Unsightly scars may often be avoided if this suture is 
used. The suture material will become absorbed or encysted in 
a few weeks, or if the free ends are tied together and the suture 
afterwards removed by cutting the loops and drawing out the 
suture by one end. 

Lembert Suture. — This suture is much used in abdominal 
operations and in wounds of the viscera covered with peritoneum. 



142 



MINOR SURGERY. 



A round needle threaded with fine catgut or silk is first passed 
through the peritoneal and muscular coats of the intestines a few- 
lines distance from the wound, and it is then carried across the 
wound and passed through the same parts of the intestine the 




Fig. 44. Halsted's subcuticular suture. 

same distance from the edge on the opposite side. The sutures 
are then tightened, the peritoneal surfaces are inverted and 
brought into close contact with each other. This suture is often 
indicated in abdominal operations. 

The Removal of Sutures. — Sutures which do not set up 
irritation may be allowed to remain in situ until there is firm 
union and the wound is healed. From ten to fifteen days is suffi- 
cient time in an aseptic wound; after this time the suture material 
above the wound may be cut on one side of the knot, and if trac- 
tion be made on the side of the knot that part that remains unab- 
sorbed can easily be removed with forceps, or will come off in the 
dressings. Silk, silver wire, horse hair and silkworm gut are 
removed in a similar manner, though with the silver wire suture 
one end should be unfastened and the suture removed in the 
direction of its curve. 

Sutures that are properly prepared ought not to cause irrita- 
tion of the tissues. Silk and silver wire may be used for buried 
sutures, and if left under the tissues become encysted. If on in- 
spection of the wound it is found that the sutures are causing 
irritation by their presence, they had best be removed and straps 
of adhesive plaster applied to hold the wound-edges together. 



CHAPTER XIII 



INFECTED WOUNDS. 

These wounds are more often due to accident, and are produced 
by the introduction of specific bacteria and by means of an abra- 
sion of the skin that may be so tiny as to escape notice. Absorp- 
tion of poisons by the suderiferous and sebaceous glands also 
cause infection. Injuries received while doing operative work 
upon the cadaver are common examples of poisoned wounds. 
Some surgeons hold on the basis of bacteriological examination that 
all wounds accidentally inflicted are infected. It is apparent that 
when the physician is called to treat a wound its thorough disin- 
fection must be the first aim in view. Just how long a wound 
may remain infected before it be thoroughly cleansed is an im- 
portant question. Schimmel busch inoculated the end of the tail 
of a mouse with cultures of anthrax, and ten minutes later ampu- 
tated the tail at its root. The animal died from the disease. It 
is said that one minute after inoculation a thorough antiseptic 
treatment is powerless to prevent infection. Powerful antiseptics 
devitalize the tissues, and while they destroy the bacteria upon 
the surface they rarely render the wounds perfectly sterile. If 
the wound is treated immediately, antiseptics may prevent further 
trouble, while if some time has passed the best idea is to place the 
wounded parts in the best possible condition for resisting by their 
vital action bacterial infection. 

The surgeon should aim to accomplish thorough cleanliness bj 7- 
adopting all precautions customary in preparing for an operation. 
Foreign bodies and blood clots are washed out with the aid of a 
stream of the normal salt solution or a bichloride of mercury solu- 
tion, i to 2000. A thirty-grain solution of chloride of zinc is 
effective in septic wounds. The wound is then treated on general 
principles according to the variety. If infection is later demon- 
strated, the treatment has for its main objects cleanliness and 



144 MINOR SURGERY. 

drainage. The wound cavity should be packed and covered with 
gauze saturated in some mild antiseptic solution. Oiled silk or 
any other impermeable material ought not to be used, as evapora- 
tion is prevented. The subsequent treatment depends on the 
progress of the infection ; when the neighboring structures are not 
involved and there is no involvement of the lymph channels the 
attention is devoted to the neighborhood of the wound. One or 
more dressings are required daily, and the wound redressed as 
advised. When lymphangitis and lymphadenitis occur it is some- 
times necessary to provide better drainage, and multiple incisions 
are not infrequently required. 

The application of compresses soaked in lead water, a teaspoon- 
ful to a pint of sterile water, to the adjacent structures giving 
the parts absolute rest will aid. 

Poisoned wounds, as a rule, are on the extremities, and except 
in the severest forms of blood poisoning, the infective inflamma- 
tion is worse in the neighborhood of the wound. The prolonged 
use of local hot baths is easy of application and is effective. As 
much of the part as possible is placed in a vessel with water as 
hot as can be borne for two hours, the water being kept hot. 
The treatment is given three times a day, and in the intervals 
hot compresses applied. 

Constitutional symptoms varying in severity follow infection. 
If the case is neglected general sepsis, a fearful disease, occurs 
and death is often the result. The treatment of sepsis is beyond 
the scope of this volume. 

Dissection wounds should be immediately cleansed, sucked and 
cauterized with a drop or two of fuming nitric acid. 

INCISED WOUNDS. 

This variety of wounds when made by a surgeon, in the course 
of an aseptic operation, may be regarded as surgically clean unless 
symptoms arise to disprove the supposition. As a rule an incised 
wound heals readily if properly treated, even those the results of 
accidents. Operative wounds have been already considered. 
Accidental incised wounds should, as a rule, be treated antisep- 
tically. If there is hemorrhage of course the first step in the 
treatment is to control it by the use of ligatures. When there is 



INCISED WOUNDS. 145 

considerable oozing it will be necessary to pack the wound with 
dry antiseptic gauze. A stream of 1 to 2000 bichloride solution 
should be allowed to run into the wound, and so cleanse it of 
blood clots or foreign bodies. Sterile water is also of value for 
irrigation. The location of the wound may determine the next 
step. For instance should the wound be of the forehead or face 
where healing b}^ granulation must result in an obtrusive scar, 
the surgeon ought to make more determined efforts to cleanse the 
wounded tissues thoroughly. The wound should be rubbed with 
a pad of cotton soaked in bichloride solution, or scrubbed with a 
clean brush, or scraped with a sharp spoon and then again irri- 
gated with the antiseptic solution. 

On exposed parts, like the face or neck, the so-called sub- 
cuticular stitches should be used. 

Catgut is best for suturing. Where the subcuticular stitches 
are not used interrupted sutures are introduced, the stitches being 
placed not too closely together. 

In superficial wounds when the hemorrhage has been stopped 
it will be necessary to provide for drainage. If the wound is 
rather a deep one, and the more important structures as muscles, 
tendons or nerves are divided it will be necessary to use buried 
sutures of chromatized catgut, and so approximate the divided 
structures. Superficial interrupted sutures of silk or catgut are 
introduced if drainage of the wound is omitted. The advisability 
of drainage will depend upon the probability of infection in spite 
of one's efforts to thoroughly cleanse the parts. When the injury 
is caused by a decidedly dirty instrument, or when the patient's 
skin is very unclean, it is a good rule to omit sutures and pack 
the wound with antiseptic gauze and cover with gauze soaked in 
a 1 to 2000 bichloride solution. 

If the wound seems in a healthy state later, an attempt to close 
it by sutures may be attempted. 

Incised wounds that are closed should be covered with a dry 
aseptic dressing, which, in the absence of symptoms, may be left 
undisturbed for four or five days, when the dressing should be 
removed, the wound inspected and redressed. Stitches should be 
removed in from seven to ten da3^s, and the wound protected with 
a pad of gauze and bandaged until healed. 

Aconite, Arnica and Staphysagria are the important remedies. 
1© 



146 MINOR SURGERY. 

CONTUSED WOUNDS. 

These wounds are usually made by some blunt object coming 
forcibly in contact with the soft tissues. When the skin is 
broken there is really a wound of the lacerated variety, and 
should be treated as such. When the skin is unbroken the sub- 
cutaneous tissues are more or less extensively injured, and there 
is usually considerable swelling at the site of the injury caused 
by the formation of a blood tumor or hematoma. The effusion is, 
as a rule, absorbed, though it may be removed. Contused 
wounds are best treated by rest and the application of cold com- 
presses or some soothing lotion as opium and lead water in the 
proportion of a teaspoonful to a pint of water. Pads of gauze 
are wrung out in this solution, applied and bandaged over the in- 
jured area, and may be continued until relief is obtained. If the 
hematoma remains, is tender and causes pain for a week or more 
after the injury, the contents must be removed by aspiration or 
evacuated through an incision. The latter method of treatment 
will be required when the tumor contents are too solid to be 
removed by the needle. The skin should be carefully prepared, 
as of course should the instruments and hands of the operator. 
A local anaesthetic will prevent pain. A minute incision, not 
more than one-third of an inch in length, should be made where 
the skin is thinnest over the mass. The contents of the tumor 
are expressed, gentle massage being made towards the opening. 
It is necessary to continue the gentle pressure until the contents 
are pressed out and an aseptic dressing applied, otherwise the 
walls of the cavity might separate and so admit air and increase 
the possibility of infection. A thick pad of gauze, large enough 
to cover the boundaries of the cavity, should then be bandaged 
firmly in place so as to promote the adhering of the walls. 

Should infection and suppuration eventually occur the cavity 
will require to be opened and treated as an abscess. Aconite and 
Arnica are the important remedies. 

PUNCTURED WOUNDS. 

Punctured wounds are made by sharp pointed instruments. If 
the object is clean and enters a comparatively clean surface and 






PUNCTURED WOUNDS. 1 47 

does not involve important structures no special treatment will be 
required other than the usual surgical cleanliness. 

The dressing consists of a dry pad of aseptic gauze held in 
place by a bandage or adhesive plaster. This application is left 
undisturbed for four or five days unless local wound complications 
arise. 

Punctured wounds of a more serious type cause injury to blood 
vessels with concealed hemorrhage as a result. In such a case 
the wound will have to be enlarged, the bleeding point sought 
for and the hemorrhage controlled. Occasionally a portion of 
the object causing the injur)* will remain in the wound causing 
unpleasant symptoms, as hemorrhage, neuralgias and an un- 
healthy condition of the wound. It is important to remove the 
offending bodies, and often the wound is converted into one of 
the incised variety, and sometimes with the aid of the Roentgen 
Rays bits of glass or metal can be located and easily removed. 

Tetanus is not infrequently observed as a complication with 
punctured wounds, and the physician's efforts had best be directed 
to avoid infection of the parts. Punctures made by vulnerating 
bodies known to be unclean and into tissues in the same state had 
best be treated as if infection had already occurred. Soaking 
the part, if it be an extremity, in a bichloride of mercury solution 
or the application of gauze saturated with the same solution 
is good treatment. Of course the wound should be thoroughly 
cleansed. 

The wet dressing is not disturbed for twenty-four hours unless 
there is an indication for earlier interference. Pain, slight eleva- 
tion of temperature, chills, redness and swelling of the wound 
edges indicate infection. The treatment then is to enlarge the 
wound and provide drainage and apply wet dressings. 

Even trivial punctured wounds may bring disastrous results. 

Aconite, Arnica and Ledum are the most important remedies. 

LACERATED WOUNDS. 

This type of wound is usually the result of accident, and being 
seldom aseptic should receive antiseptic treatment from the very 
first. The first step in the treatment is to control hemorrhage 



I48 MINOR SURGERY. 

when present. This being checked disinfection should be at- 
tempted. The wound is first cleansed with soap and water with- 
out much force. Irrigation of the parts with a 1 to 2000 bi- 
chloride solution is next in order. Foreign bodies imbedded in 
the tissues must be removed, as their presence prevents healing. 
Careful examination should be made at the first dressing in order 
to learn the anatomical relation of the flaps of the wound. 

If the tendons or nerves are divided they should be united 
early, with the aid of a general anaesthetic. In the majority of 
cases neither general or local anaesthesia will be required. It is 
not always an easy matter in an extensive laceration to revise the 
wound accurately, though if this can be done so much the better. 

The edges of the skin are apt to curl under and an attempt 
should be made to keep them everted until the dressing is applied. 
Some surgeons use sutures, but our personal rule is to almost 
invariably avoid the use of suture material. 

We do not cut away any more of the. lacerated tissue than is 
really necessary, for it is better to apply dressings with question- 
able tissue remaining than to sacrifice tissue that might have 
been saved. In the rare cases where stitches are taken it is best 
to use silk worm gut, and the needle is introduced far from the 
wound edge to avoid devitilizing the tissue, because of the cut- 
ting off of the circulation. In the larger part of lacerated wounds 
we bring the torn tissues into apposition as nearly as possible, 
and hold them there by a gauze bandage that has been soaked in 
a 1 to 1000 bichloride of mercury solution. 

A liberal amount of gauze saturated with the same solution is 
applied over the initial gauze bandage, and over this a dry layer 
of gauze is spread and a second bandage is adjusted. It is a good 
plan to give the parts rest, and this point is of special importance 
when the laceration is near a joint. 

The primary dressing is not disturbed for forty-eight hours if 
all goes well. Then it is carefully removed, and if there are no 
indications of local sepsis a new dressing composed of gauze 
wrung out in the bichloride solution is quickly applied. This 
makes a moist dressing, and is not a wet dressing. The wound is 
inspected every second day, and the moist dressings kept up un- 
less granulations appear, when it will be necessary to use per- 



GUN SHOT WOUNDS. 



149 



oxide of hydrogen and a dusting powder. Boracic acid or Noso- 
phen are good applications. We never use Iodoform. The 
dusting powder is used until a permanent crust forms over the 
wound. 

Aconite, Arnica, Calendula and Hypericum are often indicated. 
Hypericum is of much value where there is considerable lacera- 
tion of nerve tissue. 



GUN SHOT WOUNDS. 

These wounds may be very properly divided into two classes — 
those received in civil life and those occurring in military prac- 
tice. The experience of army surgeons in the late wars has done 
much to revolutionize former ideas and methods of treatment. 

The high degree of velocity (2,000 feet per second), the coni- 
cal form and small size of the vulnerating bodies, and also the 
comparatively aseptic condition of the missies render the bullet 
wounds received in war of a much less serious nature than when 
it was the practice to use bullets of larger caliber and low veloc- 
ity. The missies used in former times were in a state of chronic 
uncleanliness, and caused ugly wounds where the bullet entered, 
and also at the point of exit. 

In addition to the ordinary effects of a bullet wound infection 
occurred altogether too frequently. 




1234 

Fig. 45. (1) End view of 2, Krag-Jorgeusen bullet. (3) Mauserlbullet. (4) Lee- 
Metford bullet used by the U. S. Navy. 

Modern rifle bullets are coated with jackets of tin, nickel, 
copper, steel or zinc. So-called dum-dum, or soft nose bullets, 
are not covered with metal mantles. 



150 MINOR SURGERY. 

The force of the contact of such a missile with the tissues re- 
sulted in the soft lead becoming irregular in form and so causing 
a more or less extensive laceration of the soft and bony parts. 

The action of the modern bullet upon the human tissues de- 
pends upon the range at which it is fired. At short ranges, 
within two hundred yards, it has an explosive character. If 
fired at longer ranges it makes a clean drilled hole in the bone, 
and if it strikes soft parts only a very small wound is made, and 
there is but slight hemorrhage unless an important vessel is 
wounded. The Mauser bullet has been described as a merciful 
one because of the trivial wounds it causes when fired at not too 
close range. The Martini-Henry bullet is a heavy one and 
causes great destruction of tissue. It is really wonderful how 
many soldiers have recovered when even so-called vital organs 
have been wounded. 

Wounds of the head with considerable destruction of brain 
tissue very often make good recoveries. . 

Wounds of the chest, even when the lung tissue is entered, 
heal readily. 

Penetrating wounds of the abdomen and joints have healed 
kindly in many instances. More often the military bullet pierces 
the body, leaving a larger wound of exit than at the point of 
entrance. If an antiseptic dressing is early applied, and the 
parts put at rest the wound, as a rule, heals without symptoms, 
providing the larger vessels escape injury. 

In civil life the wounds vary according to the missile, the tj^pe 
of arm, the explosive used and the distance between the body and 
the weapon. As the projectile is usually of low velocity the 
wound is not of the clean-cut type, but is rather ragged in ap- 
pearance, and because of the unclean condition of the unjacketed 
bullet there is a stronger possibility of sepsis intervening. 

The first point to be observed in the treatment of bullet wounds 
is to stop the hemorrhage. It may be even necessary to convert 
the wound into one of the incised variety and so expose the 
wounded vessels. As shock is very often present measures must 
be taken to combat this often serious condition. The wound 
itself should be treated antiseptically, and if a bone has been 
injured the treatment of a compound fracture should be instituted. 



GUN SHOT WOUNDS. 151 

The advisability of removing the offending body is a question 
of importance that may be decided after considering its location 
and also the possibility of causing future complications if allowed 
to remain in the tissues. Lodged missiles often become encysted 
in the tissues and cause no trouble. Again, they induce suppur- 
ation or cause pain or neuritis by pressure upon a nerve, and 
interfere with motion by involving a joint. Mental disquietude 
arises at times even though the bullet is doing no harm. A 
missile which is doing harm should not remain in the tissues, pro- 
vided it can be removed with safety to the patient; but it is not 
wise to attempt to remove a missile when the operation would be 
more dangerous, or cause more discomfort to the patient than 
would the presence of the foreign body. 

Bullet wounds should not be probed except in cases of urgent 
necessity. 

Bullet wounds, even those made with large lead missiles, will 
generally heal without symptoms if left unprobed. It is a good 
plan to consider all bullet wounds as infected, but not to an extent 
sufficient to cause inflammation, because the natural resistance of 
the tissues is usually sufficient to overcome the infection. How- 
ever, if the tissue resistance is lowered by undue examination by 
fingers and probes inflammation may occur in wounds which 
would heal without symptoms. In some instances the location of 
the foreign body is imperative, and for this purpose there has 
been devised an electric telephonic bullet probe. 

Nelaton's probe has a porcelain tip on which the lead bullet 
leaves a stain when coming in contact, thus denoting the position 
in the wound. The use of the Roentgen ray makes it possible to 
localize lodged missiles without interfering with the original 
wound. 




Fig. 46. Bullet forceps. 

When it is necessary to search for a bullet the operation should, 
of course, be characterized by rigid aseptic precautions. 



152 MINOR SURGERY. 

Blank cartridge wounds consist of burns and lacerations, and 
not infrequently the wad is forced into the tissues. There is 
danger of tetanus in wounds of this character, so thorough efforts 
must be made to disinfect the parts and remove all foreign sub- 
stances. Hemorrhage should be checked if present, and the 
wound packed and dressed with wet antiseptic gauze. 

SNAKE BITE. 

Bites of venomous reptiles are not always fatal, though often 
dangerous. The treatment may be summarized briefly as follows: 
Stop immediately the circulation in the bitten member or part of 
the body so as to prevent absorption of the poison. This is easily 
accomplished by placing one or several ligatures above the wound. 
The parts should be incised deeply, and the fang wound well 
scarified. In cases seen early the wound should be sucked forci- 
bly to attempt to extract the poison, and this may be accom- 
plished by the mouth or with a cupping glass. The poison is 
rather harmless when swallowed. Calmette's antivenene serum 
has been proven a powerful remedy against snake bites, and it is 
said to act on patients who are apparently dead. Two and one- 
half to five drachms of this serum injected hypodermically and 
frequently repeated are highly recommended. If the serum can- 
not be had injections should be made of three to six drops of a 
fresh 10 per cent, aqueous solution of calcium chloride at several 
points near the bite and elsewhere. Gold chloride is equally 
effective. Permanganate of potash is of little value. Stimulants 
are often required and may be given freely. Strychnine, atro- 
pine, whiskey, the normal salt solution, lavage of the stomach, 
and artificial respiration are indicated. The patient should be 
encouraged continuously because of the deep mental prostration 
which occurs with the physical depression of the nervous system. 

DOG BITE. 

Persons bitten by dogs, cats, wolves or foxes are not necessarily 
exposed to rabies. To prevent the occurrence of hydrophobia it 
is a good plan to suck the part as soon as the bite has been 
received. The wound should be well cleansed by a 1 to 1000 



DOG BITE. 153 

bichloride solution, and several minims of the same fluid should 
be injected into the tissues for at least an inch around. Fuming 
Nitric acid or Carbolic acid, C. P., should then be used to cauter- 
ize the parts. Nitrate of silver is useless for this purpose. A 
wet antiseptic dressing should be applied. If the bite is made by 
suspicious animals it is well to send the patient to New York 
City for the Pasteur treatment. 



CHAPTER XIV 



BURNS AND SCALDS. 

A burn is a high grade of acute inflammation following the 
application of dry heat to a portion of the cutaneous or mucous 
surfaces. A scald is due to moist heat. 

The effects of burns and scalds are both local and constitutional. 
The local effects for convenience sake may be divided into three 
degrees. 

In burns of the first degree the effects are a superficial hyper- 
emia, such as are caused by a close proximity to heat or to the 
rays of the sun. In burns of the second degree the inflammation 
in some cases destroys the upper layers alone of the cuticle, and 
vesicles will be formed over the affected surface. The papillary 
vessels are deeply congested or ruptured. In this class of burns 
the destructive process is due to actual contact with the heated 
substances which may be heated metals, the actual flame or boil- 
ing liquids. 

In burns of the third degree the superficial structures may still 
be the only tissue involved, but rather a large area is destroyed, 
or it may be deep, destroying the subcutaneous tissue, nerves, 
vessels, muscles and bones. The amount of charring is great, 
and in some instances the degree of loss will be to such an extent 
that the bone will be entirely denuded. Hemorrhages, fractures 
and constitutional effects often occur as complications in this 
type. 

Constitutional Effects. — In burns of the first and second 
degree the effects upon the system are, as a rule, more slight and 
are limited to pain and possible shock. With the third degree 
burn the pain and shock are much more severe, and death is often 
the result. Vomiting and increased temperature may also be 
recorded as well as inflammation of some of the viscera. 

Treatment. — Active constitutional treatment is to be directed 



BURNS AND SCALDS. 155 

toward the relief of shock and pain. Stimulants and anodynes 
are indicated. The functions of the various internal organs are 
to be watched, and any irregularity of their functions must be 
early attended to. Local treatment has for its aim the limita- 
tion of the resulting inflammation, the prevention of septic infec- 
tion, assisting the normal elimination of the eschar, the preven- 
tion or limitation of the deformity, and the development of 
healthy granulations. In burns of the first degree little or no 
treatment is necessary, though cocaine ointment, 4 per cent., 
relieves the pain. Flexible collodion benefits first degree burns 
by preventing contact with the air. Flour and lard mixed to- 
gether is a good home remedy, so is the bicarbonate of soda, and 
also the white of an egg and sweet oil. Picric acid at a strength 
of 1 to 200, or saturated solutions, are especially good. This is 
antiseptic and analgesic, and is much used. The acid is applied 
on strips of gauze, which are soaked in the solution, and band- 
aged in place. Picric acid acts by coagulating the albuminous 
exudations. It is also of service in second degree burns. In 
burns of the third degree it checks suppuration but does not 
hasten granulation. 

In burns of the second and third degree more active measures 
are called for. The clothing over the burned area should be 
gently removed and the burned or scalded portion should be 
cleaned as thoroughly as possible with a piece of absorbent cotton 
saturated with the picric acid solution or bichloride solution. It 
is advisable to let the shreds of clothing, which have been burned 
into the skin, remain until the second dressing. The cloth has 
been ascepticized by burning and can do no harm, while removal 
will only tear away the flesh. If blisters form they must be 
pricked with a needle made sterile by passing through an alcohol 
flame, and the contents expressed. Care must be taken not to de- 
stroy the epithelial surfaces. 

Calcined magnesia is an excellent agent for the treatment of 
second degree burns. The burned area is covered with a thick 
layer of paste which is composed of calcined magnesia and water. 
This application is allowed to dry upon the skin, and when it 
falls off fresh paste is applied. Pain soon ceases after the use of 
this agent. 



156 MINOR SURGERY. 

Iodoform has been a much used drug because of its ansesthetic 
and antiseptic properties. Europhen, an iodine preparation, has 
an action similar to iodoform, and lacks the pungent odor. It may 
be employed in a powder or mixed with olive oil in the propor- 
tion of three parts of the drug to seven parts of the oil. 

Aristol is a valuable agent in the treatment of burns of all 
classes. It may be used as a dusting powder or mixed with olive 
oil, making a ten per cent, solution. This drug may be prepared 
as a cerate by taking one part of aristol, sterilized olive oil two 
parts and vaseline eight parts. When this agent is applied the 
parts must be previously irrigated with a weak boracic acid solu- 
tion, and the adjacent tissues scrubbed with soap and water and 
gently dried with absorbent cotton. The powder is then dusted 
on the edges of the wound and the cerate spread upon sterile 
gauze and applied. The gauze is covered with another layer of 
gauze and absorbent cotton and bandaged. Extensive burns of 
the third degree have been very favorably influenced by this 
treatment. One of the most important points to be regarded in 
the treatment of burns and scalds is the total exclusion of air. 
Sloughing tissues should be removed by clean instruments (scis- 
sors and dressing forceps) , and the parts cleansed each day. It 
is of the greatest importance to keep the injured part aseptic, for 
the patient may recover from the shock only to die of blood 
poisoning. This has been the case where the side of the face and 
the chest have been extensively burned. 

Tardy granulations can be assisted by sprinkling acetanilid 
powder over the surface, or by the use of europhen and aristol. 
Unhealthy granulations must be cauterized by silver nitrate stick 
or nitric acid, dilute. 

Carrion oil, a long time favorite application for burns, is com- 
posed of olive oil and lime water. It is not antiseptic, and is a 
foul mixture, but seems to control the pain in some cases. 
Equal parts of glycerine, olive oil and calendula is also a favorite 
prescription. A few drops of the tincture of opium may be 
added to the latter prescription. 

Turpentine has been successfully used in the treatment of 
burns. 

Potassium nitrate, a few teaspoonfuls in a basin of boiled 



BURNS AND SCALDS. 157 

water, is a well-tried remedy. The burned parts are soaked in 
the solution, and the bath prolonged three or four days. 

The Continuous Warm Bath. — This treatment is advised by 
Hebra in cases of extensive burns. He employed a bath tub six 
feet long and three feet broad, in the interior of which an iron 
frame was fitted, and transverse bands of webbing were attached 
to each end. It was provided with a pillow and covered with a 
blanket. At the head of the tub, but at a higher level, was a 
copper boiler furnishing water at the desired temperature. This 
was connected with the tub by a pipe, which entered at the 
bottom. Through this the water flowed continuously, escaping 
by a pipe at the water level. Thus a constant flow was main- 
tained. The temperature of the water was kept at 90 to 100 
degrees, and entirely changed every day. A wooden frame over 
which a blanket was spread was placed over the tub while the 
patient was in the bath. Hebra kept his patients in the bath for 
as long as a hundred days without removing them from the tub. 
This form of treatment has been attended by excellent results. 

Burned surfaces are to be dressed so as to prevent contiguous 
surfaces from becoming adherent. Splints placed to prevent con- 
traction of a limb are to be worn during the healing process and 
afterwards. Cavities which do not fill in require skin grafting 
and the deformities due to cicatricial tissue may be bettered by 
plastic operations. Massage should be begun early if the joint 
has been involved. Pressure on nerve filaments requires surgical 
measures. 

Aconite is indicated for the constitutional symptoms and to 
allay inflammation. Should not be given if there is shock. 

Cantharis in burns of the first and second degree where blebs 
form. 

Arnica for deep burns and where there is intense pain at the 
seat of injury. 

Arsenicum when ulcers form and gangrene threatens. 

Causticum for old burns and burns of the lips and tongue. 

Coffea to promote sleep and allay nervous excitement. 

Rhus tox. in burns with extreme vesication. There is a ten- 
dency to depression and sepsis. 

Carbo veg., Camphor and Veratrum alb. in extreme cases 
where the shock is so excessive as to threaten life. 



158 MINOR SURGERY. 



POWDER BURNS. 

This form of burn results from the explosion of gun powder, 
and in addition to the wounds of the tissues there are introduced 
into the skin grains of unburnt powder which, if not removed, 
leave permanent points of discoloration. The burns should first 
be washed with bichloride of mercury solution 1 to 2000, and the 
larger grains of powder removed, as they are in reality foreign 
bodies beneath the skin and often cause irritation and suppura- 
tion. If the face has been involved extra care must be taken, as 
the powder stains are frequently a source of annoyance from a 
cosmetic point of view. A needle or fine-pointed knife is used in 
the removal of the powder grains. The surface should be dressed 
with gauze, and an ointment composed of aristol, 1 part; steril- 
ized olive oil, 2 parts, and vaseline, 8 parts. This dressing is 
covered by a few layers of sterile cotton and bandaged. The 
dressing ought to be changed each day and the burned area in- 
spected. Grains of powder that escaped previous notice must be 
removed by a clean needle or knife point, and the parts redressed. 
If considerable tissue has been destroyed the general treatment of 
burns is indicated. 

The blue stains that so frequently result from powder burns 
often require removal. This can be successfully accomplished by 
painting on the stains the following solution: Ammonium bin- 
iodide and aqua dist., an ounce of each. This application will 
turn the stains to a reddish color. To get rid of the red discolor- 
ation it is only necessary to paint the affected parts with dilute 
hydrochloric acid. 

BRUSH BURN. 

This injury may be defined as a combination of a contused and 
a lacerated wound. While not really a burn, as the condition is 
ordinarily described, the injury presents pathological changes 
quite similar, and the destruction of the tissues varies from the 
loss of a portion of epidermis as is found in first degree burns to 
severe injuries of the deep structures. The wound is often pro- 
duced by the body surface coming in contact with rapidly revolv- 



ELECTRICAL BURNS. 159 

ing objects, as a wheel or leather and canvas belting. The body 
being forcibly and rapily propelled over a rough surface will 
cause this injury, as also will a rope drawn quickly through the 
closed hand. This class of injuries is often met by railroad 
surgeons where individuals are thrown from moving cars and 
come in contact with the rough road bed. 

Treatment. — The surface of the brush burn should be 
cleansed with sterile water or a bichloride of mercury solution i 
to 2000. Bits of gravel, cinders and other foreign bodies must 
be removed if present with the aid of a clean needle, knife point 
or curette. The dressing may consist of boracic acid and calen- 
dula, equal parts, or aristol powder and a plain gauze bandage. 
If the deeper tissues are involved the same treatment may be 
used. The wound should be dressed so as to exclude the air. 
Should pus form it is cleared away daily with peroxide of hydro- 
gen and a moist dressing consisting of gauze wrung out in a five 
per cent, boracic acid solution held in place by a bandage. 
Sloughing tissues are removed as soon as formed. Arnica, Cal- 
endula or Hypericum are indicated. 

ELECTRICAL, BURNS. 

Burns due to contact with charged electrical wires run such a 
different course from other burns of equal extent and apparent 
severity that they should be considered separately. If the skin 
be dry at the time the current is received there will be more 
burning but less penetration and less shock. If the skin be wet 
there is more shock and less penetration. 

The chief clinical features of an electrical burn are as follows: 

i. As to Appearance. — The burn is at first dried, crisp and 
may be even charred, the site being excavated and bloodless, 
with a surrounding zone of pallor. Within thirty-six or forty- 
eight hours this picture will completely change, oozing will 
replace the dryness, and the pallid zone will become hypersemic. 
In fact, the symptoms of moist gangrene will set in followed by 
rapid formation of a slough with a peculiarly fetid odor. 

2. Pain. — May be severe and require opiates for days, or may 
be slight and disappear in forty-eight hours, depending upon the 
degree of the burn. 



l6o MINOR SURGERY. 

3. Shock. — Electric burns differ from other burns, in that the 
systemic shock is from contact with electricity, and but little from 
the burn itself. If considerable tissue is involved the prolonged 
sloughing of adjacent tissues will cause a certain amount of 
shock. 

4. Prognosis. — In regard to time electric burns average one- 
half to three times as long in recovery as do other burns; in 
severe cases even five times as long. Prognosis of result is as 
uncertain as time prognosis — both mild and severe cases are 
tedious and prolonged. So much tissue is lost in the prolonged 
sloughing which no treatment seems to hasten that one has to 
wait with patience until healthy granulations replace the fetid 
sloughs. 

5. Subsequent Manifestations. — Dr. Sharp has said: ' ' The 
rule of the electric burn is that it changes within thirty-six 
hours from contact to a serum saturated area with disintegrating 
walls and floor, progressing to profuse purulent secretion, with 
continued tissue degeneration. This degeneration will frequently 
involve nerve, muscle, tendon, joint, capsule, ligaments, articular 
surfaces, periosteum and bone itself, exuberant granulations 
springing up, the entire plain bathed with pus completing a 
picture alike distressing to patient and surgeon. I have found 
that in these burns the blood shows no tendency to clot, and this 
is said to be a well known post-mortem feature of the blood of 
those who have been killed by electricity. ' ' 

The treatment is unsatisfactory and discouraging. If the per- 
son has been exposed to a strong electric current, and even is 
apparent^ lifeless, the treatment consists in practicing artificial 
respiration, friction to the surface of the body, enemata of hot 
saline solution and intra-venous injections of the same. Hypoder- 
mic injections of strychnia should be used or any other stimulant. 

The burned areas are treated according to the amount of tissue 
involved. The parts are first cleansed with a weak formaline 
solution. The next point is to promote the throwing off of the 
dried and crisp tissues which come away as a slough, and to 
accomplish this fomentations of hot saline solution should be 
applied early. After the separation of the sloughs, the subse- 
quent dressing consists of cleansing with Hydrogen peroxide 



X-RAY BURNS. l6l 

followed by irrigation with saline solution. Carbolic acid is irri- 
tating to burns, and corrosive sublimate in large areas is liable to 
prove dangerous. 

After the parts are well cleansed a dressing composed of equal 
parts of Olive oil, Glycerine and Succus Calendula, with a few 
drops of Tincture of Opium added, is applied. To prevent the 
dressings from adhering to the wound they may be laid upon 
perforated leister's protective. The dressing of these burns 
should be changed frequently; all pus should be cleared away 
with the Hydrogen peroxide; sloughing tissues should be re- 
moved as rapidly as loosened. If bullae form these should be 
opened with an aseptic needle and the contents expressed, and 
the epidermis gently replaced. The important points in the 
treatment of this class of burns are to keep the wound clean and 
aid the separation of the sloughs by the method already men- 
tioned. When the parts have become apparently aseptic Aristol 
and Nosophen, in powder form, are desirable applications. 

X-RAY BURNS. 

An inflammation of the skin due to prolonged exposure to the 
X-rays causes a dermatitis which has been termed an X-ray 
burn. It is probabty due to electrical irritation of the skin, and 
may be prevented by the presence of an aluminum plate between 
the tube and the patient while the skiagraph is being taken. 
The results of the irritation are a rather extensive degree of in- 
flammation and prolonged sloughing, which terminates in chronic 
ulcer. 

The treatment is the same as given for burns due to other 
causes; the sloughing process must be kept well cleansed, and all 
necrotic tissue removed. Peroxide of hydrogen is indicated and 
Aristol or Nosophen powder aid in the process of repair. 

BURNS DUE TO CHEMICALS. 

Burns from chemicals should be treated locally at first by weak 

acid or alkaline solutions to neutralize respectively the alkali or 

acid causing the injury. A weak carbolic acid solution will aid in 

the treatment of burns due to caustic alkalies, while a solution 

ii 



1 62 MINOR SURGERY. 

made by the addition of a tablespoonful of Carbonate of Soda will 
do much to offset the effect of the acid. The subsequent treat- 
ment is the same as has been given for burns. 

INJURIES DUE TO ELECTRICITY. 

The passage through the animal body of a strong electrical 
current produces the same effects whether the power be a light- 
ning stroke from the clouds or a current artificially produced. 
The patient struck may die immediately, or may become uncon- 
scious, and, though apparently dead, will recover if properly 
treated. The effect on the patient is shown by the unconscious- 
ness, slow, superficial respiration, dilated pupils and weak pulse. 
The respiration may not be apparent, and the pulse beat may not 
be found. Burns are produced where the current enters and 
leaves the body, and extensive laceration of the hard and soft 
tissues may be present. If the current be a slight one the person 
struck by lightning or shocked from a live wire may be simply 
knocked down and recover rapidly, or a more serious condition 
result. Partial or total paralysis, neurasthenia, shock, blindness 
or insanity have been noted in addition to the burns. The burns 
are of the same type as have been described. 

Treatment. — If the shock be due to contact with an artificial 
current the patient must be quickly removed from the wire if he 
be still be in contact with it, or the current shut off. It may be 
necessary to break the wire. The person who attempts the rescue 
ought to put on rubber gloves before touching the patient and 
should catch hold of the clothing, care being taken not to touch 
the skin. The rescuer may also wrap his hands up in a dry cloth 
and break the current by lifting the patient by the clothing from 
the earth or wire. It may be possible to slip a dry cloth between 
the patient's body and the ground and so break the current and 
make it safe for the rescuers to touch him while yet in contact 
with the earth and charged wire. A simple method of rescue is to 
push away the wire with a dry stick or cut it with a pair of wire 
cutters or scissors with dry wooden handles. 

Of course these procedures are unnecessary when the cause is a 
direct lightning stroke and also when the patient has been shocked 



INJURIES DUE TO ELECTRICITY. 



I6 3 



by a current striking an adjacent object. This class of patients 
require active treatment for a period of several hours, even though 
they be apparently dead. After the body is released from con- 
tact with the current, artificial respiration is of the very greatest 
importance and must be kept up intermittently for hours, as as- 
tonishing recoveries have taken place in persons given up for dead. 
Hypodermic injections of Strychnia are valuable. Stimulation 
by hot rectal enemas, hot water bottles, hot plates and friction of 
the skin are indicated. The patient should be early put between 
warm blankets. The intra- venous injection of saline solution is 
effective while alcoholics are contraindicated. The burns are de- 
scribed in another chapter. 






CHAPTER XV 



SPECIAL FORMS OF INFECTION. 

BOIL OR FURUNCLE. 

This may be defined as an acute, circumscribed inflammation 
and suppuration affecting a hair follicle, a sebaceous gland and 
the adjacent connective tissue. A boil may occur at any age or 
in any part of the body. The tumor is usually conical in shape 
and points rapidly. The contents of the tumor are chiefly serum 
and pus, which bursts the skin at one spot only. The base is 
slightly indurated, and the outline of the tumor is indistinctly 
circumscribed. A single boil only may be present, though there 
may be several boils occur in rapid order or even simultaneously. 
When boils come in crops the condition is known as furunculosis. 
As the boil slowly increases in size there is severe pain of a 
throbbing character, the skin becomes dusky in appearance, and at 
the end of three or four days the skin over the apex of the little 
growth gives way, and a small amount of pus exudes. At the 
opening a plug of necrotic tissue is seen, which has been com- 
monly termed the "core." This is thrown off in a day or two 
and healing commences. A boil may form but not go on to sup- 
puration and disappear without opening. 

The constitutional effects are slight in degree or absent. If 
there is one large boil or several smaller ones there is a rise in 
temperature and the patient is unable to eat or sleep. Boils 
often appear in the spring from improper living in the winter; 
they sometimes follow fevers, and also occur when there is gastric 
and hepatic disorder. 

Treatment. — If the case is seen in the earliest stage there is 
a possibility of aborting the process if the germ in the hair follicle 
can be removed. A good plan is to pull out the hair and inject 



CARBUNCLE. 165 

a minim or two of pure carbolic acid. Another method is to in- 
sert a needle attached to the negative probe of a galvanic battery 
down into the hair follicle and destroy it by the action of elec- 
tric^ . The fine point of the actual cautery at white heat is 
used in the same manner. 

If the case has progressed the poultices in common use should 
not be used. If the physician wishes to secure the action of a 
poultice, cotton wool wrung out in a two per cent. Carbolic acid 
solution, covered with oiled silk and a bandage, is the best appli- 
cation. This gives ease and seems to limit the suppuration. 
When pus has formed the region about the boil should be shaved, 
using the razor in the direction of the apex so that infection may 
not spread to healthy tissue. When there is a tendency to fur- 
unculosis it is a good plan to spread zinc oxide ointment upon the 
skin about the boil before opening it. Local anaesthesia will 
render the operation painless. A crucial incision extending just 
beyond the limits of the "core" is sufficient. Wet antiseptic 
dressings will favor the expulsion of the necrotic plug, and when 
this is thrown off dry dressings will hasten the healing process. 
A method of treatment whereby the entire process can be short- 
ened is to incise, curette the inflamed tumor thoroughly and 
swab out the cavity with carbolic acid (ninety-five per cent.). 
After healing a small scar of a bluish-red tint remains. This 
gradually turns to a dead white color that is permanent. 

Patients who are afflicted with crops of boils require a rigid 
physical examination in order that the cause may be removed. 
The remedies indicated include Mono-sulphide of calcium, one- 
fourth grain, three times a day; Arnica where there seems to be 
a tendency towards boils; Nitric acid, Silicea where there is 
excessive suppuration ; Mercurius to abort suppuration ; Hepar 
sulph. when suppuration progresses slowly. 

CARBUNCLE. 

A carbuncle is a severe localized inflammation of the superficial 
body tissues which terminates in necrosis at more than one point. 
A carbuncle usually occurs during or after middle life, and is 
chiefly developed on the posterior surface of the trunk, is seldom 



1 66 MINOR SURGERY. 

present upon the extremities, and occurs in cellular tissue which 
is largely supplied with blood vessels. The tumor is elevated, 
has a flat surface and in appearance is similar to a tea biscuit. 
The tumor never points but opens at several places and becomes 
honey-combed in appearance. The discharge is composed of pus 
and long glistening shreds of dead connective tissue. The base is 
rather deeply indurated. Constitutional symptoms consist of 
chill, fever, loss of appetite, coated tongue and prostration. These 
symptoms are often severe and even alarming. It is at times 
difficult to distinguish a carbuncle from a boil ; especially in the 
beginning, is this true. 

The pain in carbuncle is burning and throbbing. The tumor 
increases in size and in one or two weeks has attained its maximum 
proportions — which varies in size from a half dollar to that of a 
dinner plate. At this time it becomes soft, a number of sinuses 
form and with the appearance of the discharge the pain grows 
less and the patient improves. A carbuncle situated on the head 
or face is more dangerous than on other parts of the body. In 
the debilitated and aged death is not an infrequent result. 

Treatment. — The patient must be put at rest and supported 
by easily digested food and given stimulants if necessary. It is 
highly important that the septic focus be removed early and thor- 
oughly. When the patient's consent can be obtained for the 
radical treatment, a general anaesthetic should be administered 
and the skin washed and shaved. If too large an area is not in- 
volved the tumor may be excised by circular incisions. This 
gives immediate relief and is highly recommended for small car- 
buncles. The larger ones cannot be entirely cut out, though large 
parts of the necrotic tissue should be removed. For these cases 
a circular incision is made down through the infiltrated tissues, 
freely excising the sloughing mass. Strips of gauze used as 
tampons to stop haemorrhage should be packed by an assistant 
into the bottom of the incisions as soon as they are made. Other 
incisions should be made radiating from the initial circular cut to 
such a distance that healthy tissue will be reached. The greater 
part of the infected tissue may be cut away or scraped out with a 
sharp spoon. As there is a tendency towards considerable hemor- 
rhage it is necessary to make firm pressure over the wound for 



ERYSIPELAS. 167 

several minutes. Dry dressings are applied for eight or ten hours, 
when the}- are removed down to the first gauze tampons and strips 
of gauze wrung out in an antiseptic solution are applied. At 
the end of forty-eight hours the deep tampons should be removed 
and the wound inspected in order to discover possible pus pockets, 
which, if present, must be cleared away and drainage provided. 
Counter incisions will help drain the wound. Wet dressings are 
kept in contact with the parts until the necrotic tissue has been 
cleared away, and then a dry dressing should be applied. In 
some instances the part will require cleansing and redressing more 
than once a day. As a rule the unpleasant phenomena arising 
from the presence of a carbuncle disappear very quickly after the 
institution of this method of treatment. 

Certain individuals cannot or will not go through the radical 
treatment. Such cases have been treated with local applications, 
including poultices, hot compresses and antiphlogistine. Cotton 
wool wrung out in a two per cent, carbolic acid solution applied 
to the parts and covered with oiled silk is better than a poultice. 
Necrotic tissue must be removed with scissors and forceps as soon 
as loosened and the parts kept well cleaned. 

Remedies. — Arnica. — In the beginning as a prophylactic. 

Arsenicum. — Intense burning, weak and irregular pulse, cold 
sweats, emaciation, vomiting, burning thirst, septic and malig- 
nant cases. 

Belladonna. — Cerebral complications; parts red and swollen, 
red face, bright eyes and a tendency to erysipelatous inflamma- 
tion. 

Echinacea. — Sepsis due to carbuncles. 

IyACHESiS. — Prostration; parts are of purple tint, with mul- 
tiple blebs. 

Rhus Tox. — Burning and itching about the carbuncle ; stupor; 
pale face, fast pulse. 

Silicea. — When there is a copious pus discharge. 

ERYSIPELAS. 

Erysipelas is an acute, infectious disease involving the skin, 
mucous surfaces and lymphatics. It is due to the presence of a 



1 68 



MINOR SURGERY. 



pus forming germ commonly called Fehleisen's coccus which may- 
gain an entrance to the system through a wound so minute in 
size that its presence is not detected; and the disease, characterized 
by oedema and redness, is first noticed at the point of entrance a 
few hours after infection has occurred. The disease spreads 
rapidly through the superficial tissues, and when it involves the 
deeper structures suppuration is often the result. The skin pre- 
sents a special rosy color and is slightly elevated. Vesicles form, 
filled with serum, which may later turn into pus. The dermatitis 
has a tendency to spread in* all directions. Beginning in the face, 
it spreads upward usualty; on the extremities towards the trunk; 
and on the trunk it tends to spread in any direction. The disease 
in the past has been an altogether too frequent complication of 
operative wounds. In such cases the local appearance of the 
wound is indicative of the infection. The lips of the wound 
separate, the surfaces slough, there is a glazed appearance of the 
granulating surfaces and a sero-purulent discharge is present. Ex- 
tensive sloughing and hemorrhage will also occur. 

Constitutional symptoms consist of malaise, alimentary disturb- 
ance, chill, fever and burning pain. These phenomena continue 
with varying severity according to the activity of the invading 
germs and the resistive power of the individual, gradually abat- 
ing if the case is to have a favorable result. Relapses are very 
frequent. 

Treatment. — As the discharges from a part afflicted with this 
disease are extremely infectious, the attendant must be careful 
not to infect himself with the dressings. These should be burned 
immediately after being removed. The patient had best be 
isolated when practicable. The surgeon should be cautious about 
conveying the disease to other patients, and to prevent this 
should wear a linen duster or night shirt over the street clothing 
before entering the sick room, cover the head before and carefully 
disinfect the hands after the completion of the dressing. Rubber 
gloves may be worn. 

The patient must be well nourished and stimulated when 
required. Fatal terminations, unfortunately, are not rare. 

Numerous applications are recommended for local treatment. 
The latest and perhaps the best is the application of Carbolic 



ERYSIPELAS. 169 

acid, ninety-five per cent., to the entire infected area. The acid 
is allowed to remain for a minute and is then neutralized by 
alcohol, and the parts dressed with antiseptic gauze covered with 
oiled silk. This treatment has proven highly successful, the local 
and constitutional symptoms become less severe, and the case 
soon recovers. 

Another good application is composed as follows: 

Resorcin and Ichthyol, eath 5 parts. 

Mercurial ointment 40 parts. 

Lanolin 50 parts. 

This mixture is spread over the affected tissues and covered 
with gauze and oiled silk, and then bandaged in place. This 
prescription is very effective, and may be continued as long as 
there are local symptoms. 

If pus forms and threatens to burrow beneath the superficial 
structures a series of incisions will be required and drainage 
provided. Some cases will have to be curetted before healing is 
established. 

Remedies. — Belladonna. — When the skin is bright red in 
color and shining. Flushed face, throbbing carotids, brain com- 
plications. 

Rhus tox. — When vesicles form, dark bluish redness with itch- 
ing and burning. 

Apis. — Considerable swelling, burning, stinging pain in the 
affected tissues. 

Arsenicum. — In severe and septic cases. Disorganization of 
the blood. 

Graphites. — Wandering erysipelas. 

Aconite. — When the fever is high. 

ANTHRAX. 

Malignant pustule or wool sorter's disease are terms applied to 
a severe acute inflammation due to infection with the anthrax 
bacillus. The disease is common to man and domestic animals, 
occurring in the former when coming in contact with the carcases 
and skins of diseased animals that have once harbored the bacilli. 






170 MINOR SURGERY. 

The initial lesion appears either on the hands, arms or face and 
is at first a small papule which soon develops into a vesicle. This 
is surrounded by an indurated and infiltrated area which is fol- 
lowed by local gangrene. The affected tissues are discolored and 
may be quite black. As a rule, there is no suppuration, nor is 
the pain as severe as in carbuncle. If the disease is not disturbed 
and progresses favorably the infected area finally sloughs out and 
leaves a granulating surface. More often the local and constitu- 
tional symptoms of sepsis are really alarming and prompt measures 
must be taken to give needed relief. Nearly all cases when prop- 
erly treated recover with a local destruction of tissue ; though 
when sepsis is present and due to improper treatment the case will 
often have a fatal termination. 

Treatment. — The patient must be put at rest and given an 
easily digested and nourishing diet, stimulants if necessary. 
As the attendants are liable to be infected, the best treatment is 
to thoroughly excise the infected area with the actual cau- 
tery. This instrument is best to combat the destructive pro- 
cess and should be used early; in fact, as soon as the diagnosis is 
made, in order that general infection will be prevented. Thor- 
ough eradication is of importance, for if any infected tissue is 
allowed to remain a general spreading of the poison is not un- 
likely. 

The remedies given for carbuncle will be indicated. 

PHLEGMON. 

A phlegmon is an acute inflammation involving, primarily, the 
cellular tissues. The infection is a remarkably virulent one and 
in its progress causes rapid pus formation and great destruction 
of tissue. The streptococci are the infecting agents. The disease 
is sometimes spoken of under the name of phlegmonous inflamma- 
tion or suppurative cellulitis. 

The presence of a phlegmon is recognized by the acute onset of 
pain, tenderness and swelling with infection of the surrounding 
lymph channels and nodes. Redness of the skin appears and 
there are constitutional symptoms of fever, prostration and the 
more severe symptoms of a general septic condition. The infective 



ABSCESS. 171 

process destroys all tissues in the line of its path, and dissects the 
structures away from each other. 

Treatment. — The treatment of phlegmon requires early in- 
cisions and free drainage. As the pus may burrow in any direc- 
tion beneath the fascia the number of incisions should be gov- 
erned by the extent of the destructive process. The initial cut 
should be made at the most prominent part of the phlegmon and 
then a probe may be introduced in order to explore the depths 
and aid in exposing the branch suppurating tracts. Counter 
openings should be made by cutting down on the probe. The 
sinuses should be followed up and laid open freely. 

Drainage may be made by gauze or tubing; the size and loca- 
tion of the suppurating area determining this. When the infec- 
tion is in an unexposed part of the anatomy and the patient is 
indifferent to scars the incisions should be of generous proportions 
and gauze packing is indicated. If cosmetic results are desirable 
multiple small incisions and drainage by tubing is demanded. 
The dressings must consist of gauze soaked in antiseptic solutions 
(Bichloride or Boracic acid) and the wound irrigated daily with 
the same. When there is an enormous amount of discharge the 
dressings may require to be changed two or three times daily. 
Sloughing or dead tissues should be removed as soon as they be- 
come detached. If, after the phlegmon has been drained well, 
there should be a partial relapse of the original symptoms such a 
condition is due to the retention of the discharges in some portion 
of the wound. Drainage must be maintained until the wound 
becomes healthy looking, which condition is manifested by the 
disappearance of the symptoms of inflammation and the wound 
secretions become serous in character. 



ABSCESS. 

An abscess is a collection of pus in an adventitious cavity, the 
result of an acute, circumscribed inflammation due to infection 
with pus-forming microbes. An abscess may be acute or warm 
when due to pus microbes only; chronic or cold when due to a 
specific microbe, especially that of tuberculosis. 



172 MINOR SURGERY. 

An abscess may be located in any part of the body, affecting 
any of the different tissues. 

Etiology. — Inflammation due to injuries and especially the 
introduction of foreign bodies under the skin are the usual, cause 
of abvScess. Abscesses also arise with septic fevers. While blows 
do not apparently produce superficial lesions in the majority of 
cases, it is a fact that an invisible abrasion may be present and 
serve as a channel for the introduction of the pyogenic organism. 
Infection may follow weakened glands. 

Symptoms. — The local symptoms of abscess are prominent 
when the process is superficial, but when the location is deep the 
general constitutional symptoms predominate. The cardinal 
symptoms of inflammation, pain, heat, redness, swelling, impair- 
ment of function, together with fluctuation and possible chills, 
point to pus formation. These conditions always present in 
acute inflammatory processes may be masked or totally absent in 
the tuberculous variety. The latter often attain a large size, 
and last for months without their presence being detected. 

Diagnosis. — When in doubt as to the nature of the condition 
a fine trocar, or exploring needle, carefully introduced will deter- 
mine the diagnosis. 

Aneurism is the most dangerous process to fear, and has been 
erroneously punctured. Pulsating or fluctuating tumors in the 
axillary and popliteal spaces and the neck are especially danger- 
ous in this connection. 

Treatment. — The treatment may be divided into prevent- 
ative and radical. The preventive measures include local appli- 
cations and internal medication. 

If the case is seen early the suppuration can sometimes be 
aborted. Compresses soaked in 1 to 4000 Bichloride solution 
are very useful. 

If the abscess is located upon an extremity the entire part may 
be bathed in the same solution continuous^ for several hours. 

Tincture of iodine may be applied over the inflamed area every 
three hours. 

A combination of Belladonna and Mercurial ointments is very 
efficacious. 

Compresses wrung out in Goulard's solution, a tablespoon ful 



ABSCESS. 



173 



to the quart of boiled water, is a much favored application. 
Cold compresses and ice bags will often abort the abscess. Rest 
is also very essential. 

Pads of gauze wrung out of hot Boracic acid solutions, an 
ounce to a quart of water, applied as hot as the patient can bear 
them, and well covered with oiled silk to keep in the heat, are 
often effective. 




FlG. 47. Drainage tubes for abscess requiring irrigation. 

Surgical Treatment. — If suppuration cannot be prevented 
the abscess should be opened as soon as enough pus has formed 
to enable the surgeon to recognize the condition or as soon as the 
pus is discovered by the aid of the exploring needle or aspirator. 
The most rigid aseptic rules must be observed. An ordinary ab- 
scess can be opened with a small single incision, the puncture be- 
ing made painless by the application of Ethyl chloride spray or 
ice held to the part for a few seconds. If the process has gone on 
for some time and considerable pus has formed, several small in- 
cisions, or one long cut, may be necessary to evacuate and drain 
the suppurative process. If the abscess is superficial, the skin 
alone should be incised and the grooved director, or the points of 
a pair of artery forceps or dressing forceps may be introduced 
closed, and the cavity enlarged by opening the instrument and so 
permit the free now of fluid. When the cavity is thoroughly 
emptied it may be syringed out with a 1 to 4000 Bichloride solu- 
tion until all debris is removed. 

Peroxide of hydrogen is very useful to cleanse the cavity. 
Pressure with the fingers is to be avoided. The incision and sur- 
rounding area are then washed with the same solution and an 
aseptic drainage tube introduced. Plenty of gauze dressing should 
be applied. Aristol, Nosophen or Boracic acid may be dusted 
into and about the incision. If the abscess is deep the drainage 



174 MINOR SURGERY. 

tube can be shortened daily as the wound is inspected and irri- 
gated with Bichloride solution. 

In superficial abscesses drainage may be omitted after the first 
two or three days. 

What is known as the Otis method of treating abcesses has 
proven successful in a large number of cases. 

The skin about the afflicted area is scrubbed with green soap 
and washed with Sulphuric ether and then with Bichloride solu- 
tion, i to iooo. 

A narrow bistoury is then inserted in the abscess cavity and the 
contents gently, but thoroughly, squeezed out; the cavity is 
irrigated with Bichloride, i to iooo, and immediately filled to 
moderate distention with warm iodoform ointment (10 per cent. 
Iodoform and Vaseline) , care being taken not to use a sufficient 
degree of heat to liberate free Iodine. 

An ordinary glass syringe is used, the plunger being removed, 
and the barrel warmed in the flame of an alcohol lamp and filled 
with ointment by means of a spatula. On finishing the in- 
jections, at the instant of withdrawing the syringe from the 
wound, a compress wet with cold Bichloride solution is applied, 
which instantly solidifies the ointment at the orifice, preventing 
the escape of that in the abscess cavity. A large compress of 
sterile gauze is then applied. The patient is told to return in 
four days, when, if all is well, the dressing is reapplied, but if 
any evidence of inflammation is found the wound is thoroughly 
irrigated and cleansed and the injection repeated. It is simple and 
safe. The patient is not prevented from going about. 

Treatment op Chronic or Tuberculous Abscess. — The 
lesion being a tuberculous one, general treatment is indicated. 
A generous diet, plenty of fresh air, sunlight and tonics are help- 
ful adjuncts. 

Aspiration and Injection. When there are no local symptoms of 
inflammation to indicate that the abcess is soon to open, the fluid 
maybe withdrawn with a large aspirator; a fifty percent, solution 
of Carbolic acid is injected and then aspirated. This procedure 
is repeated until the solution withdrawn is perfectly clear. Five 
days later the treatment is renewed. About five treatments are 
required. 



SINUS AND FISTULA. 1 75 

A good mixture for injection is one part of Iodoform to ten of 
Glycerine or Olive Oil. 

Boric acid may also be used the same as the above. 

While there is a local inflammation and spontaneous opening of 
the abscess is possible, there should be free incision followed by a 
thorough curettage of the abscess walls. The cavity is then 
irrigated with Bichloride solution and drainage provided; the 
wound being stitched as far as the drain. Of course an antiseptic 
dressing should be applied. The incision should be free if the 
surroundings of the patient admit of carrying out the antiseptic 
precautions. 

Often when a cold abscess opens spontaneously or is incised in 
a careless way profuse suppuration and slight sepsis follow. If 
the surroundings are not fit it is better to aspirate the abscess 
rather than to incise it. 

Remedies. — Belladonna. — Affected parts bright red, throb- 
bing pain and with fever. 

Calcarea carb. — In strumous abscess. Useful in last stage 
to promote healing. 

Hepar sulphur. — To prevent suppuration. The effect is 
often marvelous. 

Mercurius. — When glands are much involved. The swelling 
is hard and throbs. The pain is worse at night. 

Silicea. — One of our leading remedies in chronic abscesses that 
refuse to heal. Old sinuses that are hard to heal. When bony 
structures are involved. 

SINUS AND FISTULA. 

These conditions may be termed suppurating channels abnor- 
mally connecting various parts of the body. They may be con- 
genital in origin or due to an unhealed abscess, traumatism, 
foreign bodies and necrotic tissue. 

Treatment. — First remove the cause if it can be found. If 
the cavity is so situated that a probe can be passed through it, 
the parts should be laid open under antiseptic rules and the walls 
of the channel thoroughly scraped with a sharp spoon curette. 
If possible, a good method of treatment is to dissect out the lining 



I76 MINOR SURGERY. 

membrane. The part is then packed with gauze and left to heal 
by granulation. If there are multiple channels each should be 
laid open and treated. In some cases daily irrigation and cleans- 
ing with Bichloride of mercury solution, 1 to 2000, or Peroxide of 
hydrogen will tend to promote healing. It is often necessary to 
stimulate the parts to heal, and injections of Nitrate of silver 
solution, 20 to 30 grains to the ounce, or even the solid stick of 
Silver nitrate may be used effectively. Zinc chloride may be 
used in solution for the same purpose. Where there has been a 
local tubercular infection a limiting membrane lines the channel. 
If this can be thoroughly dissected out it is often possible to con- 
vert the process into a healthy condition, and stitches are taken 
and so obtain primary union. 



CHAPTER XVI. 






REGIONAL MINOR SURGERY. 

THE HEAD AND NECK. 

WOUNDS OF THE SCALP. 

Scalp wounds may be either contused, lacerated, incised or 
punctured. Contused wounds are not of much importance sur- 
gically, as they are transient in character, though they cause 
swellings of considerable size in a very few minutes. These 
lumps often feel as if they contained fluid, but when cut down 
upon none is found. The swelling is due to the injection of the 
areolar tissue. When there is no laceration of the scalp contused 
wounds are easily and effectually treated by the application of 
cold compresses, the ice bag or gauze pads soaked in a solution of 
lead water, one teaspoonful to the pint of water. 

Lacerated wounds are of a more serious nature and occur fre- 
quently. This class of scalp wounds may be extensive, even 
half the scalp being torn. The bone is sometimes fractured, and 
splinters are driven into the scalp, thus decreasing the prospects 
of a good result. The head coming in contact with some variety 
of blunt force is responsible for the lacerated wounds. Foreign 
bodies are introduced, and often much time is lost before the 
patient presents for treatment. This of course lessens the possi- 
bility of early repair and favors infection. 

Incised wounds are not of great importance unless a consider- 
able area is divided. They usually heal readily, and in two or 
three hours there is good union if there has been correct apposi- 
tion of the parts. The chances of infection are not so great as in 
the lacerated variety because the injury is so often inflicted with 
a sharp edged implement. Punctured wounds are often serious 
because the tissues of the scalp glide over each other and shut off 
12 



178 MINOR SURGERY. 

the outlet for contained pus, serum and blood which may be 
dammed up in the bottom of one of these wounds, and the pus 
burrows about between the soft tissues and pericranium. This 
condition gives rise to the so-called floating scalp, in which the 
scalp is really raised from the skull because of the great accumu- 
lation of pus. The eyelids are swollen, the forehead bulges and 
symptoms of sepsis intervene. Multiple incisions at the most 
dependent portions of the scalp is the treatment for this condi- 
tion. Vertical incisions in the back and side of the head and 
horizontal at the forehead will prevent undue scarring. The pus 
should be cleared away as thoroughly as possible. Fine rubber 
tubes are inserted for drainage and left in place until the condition 
improves, and wet dressings should be altogether employed. 

Fortunately the healing power of the scalp is very great, due 
to the free vascular supply. The complications most frequently 
attending open scalp wounds are simple inflammation and sup- 
puration, erysipelatous infection and gangrene. Erysipelas is 
more often met with in conjunction with scalp injuries than in 
those of any other part of the body. The treatment of scalp 
wounds in general is to first control hemorrhage, which is often 
great in even trivial wounds. A temporary dressing can be 
applied and the patient removed to a hospital or any clean room 
where solutions can be properly prepared and instruments, hands 
and scalp disinfected. Shaving of the scalp at the wound and at 
a considerable distance from it should always be done. Indeed 
some surgeons prefer to shave the entire scalp. The removal of 
foreign bodies is of great importance. Cinders, gravel and 
minute objects become imbedded in the skin, fascia, areolar tissue 
and muscles, and while it is somewhat of a task to remove them, 
one should make every effort to accomplish the purpose. Per- 
haps the best agents to aid in the removal of cinders and similar 
material is a stream of some antiseptic solution and the curette. 
Tissue that is badly lacerated and imbedded with powdered dirt 
had best be trimmed away. This class of wounds requires drain- 
age with a small rubber tube, though if it is thought probable 
that the wound will not be infected it is best not to use drainage 
at first but to apply a firmly fitting head bandage over a compress 
of gauze which will tend to close up all dead spaces, and if pus 



WOUNDS OF THE BRAIN. 1 79 

does form it will be limited to one portion of the scalp. Wounds 
that run parallel to the sagittal suture seldom require sutures 
even if of good size, simple pressure being all that is needed to 
keep the lips of the wound in apposition. Stitches are necessary, 
however, when the wound is transverse to the forehead, for the 
occipito-frontalis muscle when contracting separates the wound 
edges. Catgut makes the best suture material. Small punctured 
and incised wounds can be dressed with a ten per cent, iodo- 
form solution in collodion. A liberal amount of gauze should 
be applied in the dressing of scalp wounds and the head covered 
with a crinoline bandage, which helps to exclude the air. If 
drainage is employed the wound ought to be inspected and the 
dressings changed every twenty- four hours. In clean wounds 
the dressing can remain undisturbed until symptoms arise de- 
manding an inspection or the wound is healed. The remedies 
given in the chapter on Wounds will be indicated. 

WOUNDS OF THE BRAIN. 

Wounds of this important structure are generally found accom- 
panying fractures of the skull, though lacerated wounds due to 
sudden jarring, and punctured wounds made through the fonta- 
nelle or articular surfaces of the cranial bones and nasal and 
orbital cavities do not necessarily cause a fracture. The more 
serious wounds occur when the posterior part of the brain is 
injured and when due to splinters of a fractured cranial bone 
that are forced into the brain substance. Bullet wounds are of a 
serious nature. 

The symptoms of brain wounds consist of shock, partial or 
total unconsciousness and paralysis. The amount of brain sub- 
stance injured and its location plays an important role in the 
causation of symptoms. It is really surprising how much brain 
material can be lost or excised and recovery without loss of 
function result if the treatment is proper and rigidly aseptic. 

Treatment. — Encephalitis is not an infrequent result of a 
brain wound, and to prevent its occurrence or limit its area the 
use of antiseptics and thorough drainage are requisite. Of course 
the existing foreign object should be removed provided its re- 






l8o MINOR SURGERY. 

moval does not cause additional serious injury. The electric 
bullet probe is a convenient instrument to aid in the location of a 
bullet. A blunt-headed aluminum probe is a good instrument to 
discover a foreign object. This should be gently inserted and 
allowed to follow in the track of the offending missile, when the 
patient's head is so placed that the force of gravity will urge the 
probe to the site of the object. When there has been complete 
perforation of the skull there is a wound of exit as well as that of 
entrance. These openings may require enlarging and the debris 
cleared away. If there is no wound of exit it is very probable 
that the missile is still within the skull cavity and lodged in the 
brain. Foreign bodies in this important structure are more than 
likely to cause serious trouble, and their early removal is advis- 
able provided the operation is not attended by too much risk for 
the patient. 

If the patient is in a state of coma full anaesthesia will not be 
needed. The patient should be put in such a position as to bring 
the wounded surface uppermost. The most rigid aseptic pre- 
cautions should be taken. After the head has been well shaved 
the wound in the soft structures, may be enlarged by incision if 
necessary so that the wound of entrance will be fully exposed. 
This aperture should be enlarged with bone forceps or chisel, 
loose fragments of bone removed and any rough edges of bone 
trimmed off smoothly. If there is smart hemorrhage from a men- 
ingeal vessel the source should be discovered and the ligatures 
applied, even though a still larger wound is necessary. Bullets 
and other missiles have been known to pass completely through 
the brain, and on coming in contact with the opposite side of the 
skull rebound from this firm surface back into the brain substance 
and not into the original track. 

Iyilienthal gives the following rules to ascertain the exact point 
where the track of the bullet would emerge if prolonged to the 
surface opposite the wound of entrance: With the straight probe 
in the track pass a string around the skull, commencing and end- 
ing at the wound, and in the same plane in which the probe lies. 
This is to be determined by ' ' sighting. ' ' Mark this circumfer- 
ence by scratching the scalp with the scalpel. Now encircle the 
skull once more with the string, but in another direction, "sight- 



WOUNDS OF THK BRAIN. l8l 

ing " as before, so that the string shall again be in the same plane 
with the probe. Mark this circumference also. The point of 
intersection of the two circumferences will be the location sought, 
and the probe may be removed. With this point as a focus, an 
incision the shape of a horseshoe should be made down to the 
pericranium; this should be stripped up with the periosteal ele- 
vator and a button of bone removed with the trephine or the 
chisel, and the dura carefully inspected to ascertain whether it 
has been injured, while a dark point underneath denotes an injury 
to the brain. The dura should be incised, and the blunt-pointed 
probe gently inserted at this point and an attempt made to discover 
the second track of the missile. When this is found the bullet 
should be gently removed with bullet forceps. As the brain tissue 
rapidly comes together a small, sterilized and fenestrated rubber 
drainage tube should be quickly inserted down to where the 
foreign body was lodged. As healing progresses the drainage 
tube must be shortened gradually about a quarter of an inch at 
a time. In this manner the wound heals from the bottom without 
the danger of retention of fluids, septic or otherwise. The per- 
forating track through the head can be drained by a wick com- 
posed of parallel silk strands passed completely through the brain 
substance by attaching them to the end of the probe that is passed 
through the track and then pulled through the wound. One 
strand can be removed daily as healing progresses until there is 
none left. Unless there is considerable oozing wet dressings 
should be applied and a firm head bandage applied. 

During the convalescent stage special attention must be paid to 
the functions of nutrition and elimination. Paralyzed muscles 
should have daily treatment by massage and friction. 

It not unfrequently happens that during the progress of heal- 
ing of a brain wound there occurs a fungoid growth that is 
termed hernia cerebri. W T ith this condition there may be a dis- 
charge of lymph or pus. Cleanliness and firm bandages generally 
control the protrusion, though if too great a degree of pressure is 
brought to bear it will cause a retention of secretions within the 
cranial cavity if the wound is in a septic condition. The growth 
is often excised. If, after operations within the cranial cavity, 
the dura is carefully sutured there is less possibility of fungus of 



1 82 MINOR SURGERY. 

the brain occurring. Drainage in such cases can be secured by- 
passing very small drainage tubes or strands of horse hair through 
the dural incisions. 

FOREIGN BODIES IN THE EYE. 

Small substances, like cinders, dust, chips of stone or metal, 
are usually easily removed. Often the free flow of tears excited 
by the small body will wash it away. 

A common method is to catch the upper lid by the lashes and 
pulling it away from the eye ball and down over the lower lid, 
then letting it go so that as it recedes the under surface is swept 
by the lashes of the lower lid and so clear it out. The better 
way is to evert the upper and lower lids and inspect the under 
surfaces and cornea. Sometimes a magnifying glass is an aid. 
The upper lid is everted by seizing the lashes between the thumb 
and forefinger and drawing the edge away from the eye ball. At 
the same moment the end of the second finger is pressed against 
the skin of the lid above its edge. The patient is told to look 
down and to open the mouth slightly, and as he does so the 
lashes and edge of the lid are pulled upward toward the eye- 
brow while the upper part is tucked under it with the end of the 
second finger. The lower lid is easily turned down and the lower 
part of the sclerotic coat and conjunctiva are examined. 

The foreign body can be readily removed by a fine pointed 
probe or other instrument and a further search should be made 
in order to satisfy oneself that there are no others. Foreign 
substances imbedded superficially in the sclerotic coat and the 
cornea may be removed easily, though bodies situated deeply had 
better be sent to the oculist. Bits of steel and iron are fre- 
quently removed by the electro-magnet. Panophthalmitis is a 
complication to be feared in such cases and requires the best of 
treatment to save the eye. 

In young children it may be necessary to give a general 
anaesthetic to control them, while in older children and adults the 
instillation of a few drops of a warm four per cent, cocaine solu- 
tion into the eye from a medicine dropper will make the removal 
of superficially embedded objects about painless. The patient 



WOUNDS OF THE CONJUNCTIVA. 1 83 

should sit in a chair with the face turned upward. Effective 
illumination is obtained by the use of a lens of about three inches 
focal distance that magnify the part under examination, while 
a second lens is used to collect and transmit the rays of a candle 
flame to the parts. The cocaine solution causes a sensation of 
smarting which soon disappears and in about five minutes 
anaesthesia is produced. A sterilized eye speculum may now be 
introduced, though this is not absolutely necessary. The patient 
is warned to look at ajcertain object and not to move his eye. A 
good method to obtain temporary fixation is to grasp the con- 
junctiva near the cornea with fixation forceps. The foreign ob- 
ject may be removed by gentle scraping with a small pointed 
knife or a special fine pointed eye probe. It is highly important 
that the cornea be wounded as little as possible during the pro- 
cedure, because of the possible impairment of vision due to scar 
tissue. After the foreign substance has been removed the eye is 
washed out with a four per cent. Boric acid solution or one per 
cent, solution of Holocaine. It is a safe plan to apply a cold com- 
press of gauze and bandage for a few hours. 

When there has been considerable abrasion it is wise to apply 
cold compresses. One must be on his guard against the sensation 
which is sometimes left after a foreign object has been removed 
from the e}^e. It often feels to the sufferer as though this were 
still in the eye when it really has been removed. 

For the slight conjunctivitis resulting from the removal of 
foreign substances, an eye wash composed of a four per cent, 
solution of Boric acid to which is added four drops of the tincture 
of Aconite, is of much value. 

Cold applications are of decided service. Small pads of gauze 
or absorbent cotton large enough to cover the eye are laid upon a 
cake of ice or wrung out in the ice water, are convenient agents 
for applying cold. The pads can be changed every few moments. 
Cold applications should be continued for a few hours at a time. 
Aconite is useful for the conjunctivitis. 

WOUNDS OF THE CONJUNCTIVA. 

Lacerated wounds of the conjunctiva should be closed by 
suture. The operation may be performed with the aid of cocaine 



I 84 MINOR SURGERY. 

anaesthesia, though children will require a general anaesthetic. 
The patient had best lie down on a table or sit in a reclining 
chair with the head thrown well back. The surrounding tissues 
are then washed with soap and water, and again with a four per 
cent. Boric acid solution. The same solution should be allowed 
to gently trickle over the eyeball. Holocaine in one per cent, 
solution, a drug having a combination of antiseptic and anaesthetic 
properties, is much used by the oculist in eye work. A sterile 
eye speculum is inserted and a few drops of a warm three per 
cent, solution of Cocaine, made with distilled water, is dropped 
into the conjunctival sac. It is a good plan to instill a drop or 
two of the same solution into the unaffected eye to prevent the 
somewhat unpleasant sensation which occurs when one pupil is 
dilated and the other remains normal. 

An assistant steadies the globe with fixation forceps, grasping 
the conjunctiva when the wound is in good view. Only the finest 
needles and fine black silk should be used for suture purposes. 
A bandage and pad had best be worn, and if inflammatory symp- 
toms develop the application of cold is advisable. The stitches 
can be left in place for a few days and then removed if the wound 
appears healthy. 

WOUNDS OF THE LIDS. 

A wound of the eyelids should be closed when there has been 
accurate coaptation of the lips of the wounds. The surrounding 
tissues as well as the wound should be disinfected with a four 
per cent. Boric acid solution. The local application of a few 
drops of a four per cent. Cocaine solution will limit the painful 
sensation and permit more thorough work. If the wound is a 
large one and the patient be of a nervous temperament, a general 
anaesthetic may be required, while in children it is more likely to 
be necessary in order to control the little patient and also to 
guarantee the possibility of accurate approximation. When the 
wound involves the skin only, sutures of fine black silk will draw 
the edges together. If the tarsal cartilage has been severed mul- 
tiple sutures will be necessary. 

The needle should enter the skin and go through the cartilage 



CARBUNCLE OF THE LIP. 1 85 

at the same time, taking as many sutures as the dimensions of the 
wound demand. It is not really necessary to stitch the con- 
junctiva. 

Cutaneous stitches can be taken to approximate the edges 
more evenly and thus avoid unnecessary scarring. A gauze pad 
and bandage should be worn for a few da3's. The stitches 
through the skin alone may be removed in five days, though 
those passing through the tarsal cartilage should not be taken 
out for ten days. ^ 

Cold compresses are of service if inflammatory symptoms inter- 
vene. 

CARBUNCLE OF THE LIP. 

Extreme pain and extreme constitutional disturbance char- 
acterize this affection. It is a fact that it may have a fatal issue 
because of its liability to cause thrombosis of the facial vein 
which may extend to the deep jugular vein. There is a consider- 
able degree of inflammatory swelling, causing great distortion 
of the lip and involvement of the whole side of the face until the 
eye is closed. 

Treatment. — A general anaesthetic should be given and the 
parts cleaned. An incision of liberal dimensions should be made 
deeply along the line of junction of the skin and vermillion 
border dividing the lip into two parts by carrying the cut com- 
pletely through the inflamed tissues. This procedure excites 
rather severe bleeding, but it is not necessary to tie any vessels 
except the coronary artery. The wound edges are held apart 
by retractors and several strips of dry sterile or bichloride gauze 
should be packed to the bottom of the wound with the aid of 
dressing forceps. 

The wound and lip are then covered with layers of dry gauze 
and held in place by a bandage. The pressure afforded by the 
gauze and bandage will, in the majority of cases, prevent serious 
bleeding. At the end of six or eight hours the dry packing 
should be changed for a moist dressing consisting of strips of 
gauze wrung out in salt solution or Bichloride of mercury, 1 to 
2000 solution. The moist dressing need not be disturbed except 
for hemorrhage, till forty-eight hours have passed, and then it can 



1 86 MINOR SURGERY. 

be renewed. The subsequent treatment is the same as the general 
treatment of carbuncles. These radical measures are the best 
form of treatment, as there is usually little or no trouble with the 
healing process; the wound recovering quickly, and a very slight 
scar results in the muco-cutaneous margin. Many hours of in- 
tense suffering are averted and the patient makes a quicker 
recovery. 

PERITONSILLAR ABSCESS. 

The condition known as Follicular Tonsillitis or ' ' quinsy ' * 
may terminate in a suppuration of the cellular tissues about the 
tonsil. There are constitutional symptoms consisting of chill 
and fever, together with painful deglutition and an accumula- 
lation of thick, stringy mucus in the throat. The voice changes 
because of the swelling and immobility of the inflamed palate. 
If a light be thrown into the throat by the reflecting head 
mirror the tissues from the soft palate above the inner side of the 
tonsil will be found to bulge. If pus is present the examining 
finger will discover a semi-fluid mass with a soft spot where the 
pus ' ' points " or is near the surface and if not evacuated will 
rupture. 

Treatment. — Incision with a sharp pointed knife and 
liberating the pus will give the patient almost instant and per- 
manent relief. 

An anaesthetic is not required, though the puncture can be 
made painless if a four per cent, solution of Cocaine is swabbed 
over the affected mucous membrane. 

The patient should sit in a good light, as the head-reflector is 
of much service. 

The tongue is controlled by a tongue depressor or spoon 
handle. If the soft spot, denoting pus, is easily detected, the 
surgeon should incise the indurated mass at a point equally be- 
tween the upper part of the tonsil and the inner border of the 
swelling, holding the knife with its edge downward and inward and 
cutting in the same direction toward the edge of the soft palate. 
This incision will relieve nearly every case. If pus is not found 
the exact location can be determined by the use of the aspirating 
needle. When the cavity is discovered the needle is detached 






RANULAE AND CALCULI. 1 87 

from the syringe and serves as a guide for the knife which is in- 
serted alongside of the needle. The pus cavity should be 
syringed out with Peroxide of h} 7 drogen and cleansed several 
times daily with the same preparation. For several days sub- 
sequent to the operation the wound ought to be examined with 
a blunt probe in order that }he edges may not adhere and so 
cause retention of pus and an exacerbation of the original 
trouble. 

RANULAE AND CALCULI. 

This is a term used to describe any of the obstruction cysts of 
the mucous and salivary glands under the tongue. 

The more prominent cause of the obstruction is an inflamma- 
tion involving the ducts of the glands and causing the formation 
of plugs of mucus which contain lime salts. 

Perhaps the form of ranula most frequently noticed is of the 
sublingual gland. It is painless and forms on the floor of the 
mouth between the tongue and jaw, is tense, translucent and has 
large veins on its surface. Its size may increase until the tongue 
is pushed up and there result difficulties of speech, respiration, 
feeding, and the tumor may extend almost out of the mouth. 
Should suppuration occur and a stone form, pain will be present. 

Ranula in the duct of Blandin is attached to the tongue be- 
neath its tip, not involving the floor of the mouth. The tongue 
can be protruded and the tumor is transparent and fluctuates. 

A ranula in the position of the incisive gland is just behind the 
lower jaw and pushes up the frsenum. A ranula of the sub- 
maxillary salivary gland may affect the intra-buccal portion or 
the external part of the gland may be affected and a cyst form 
and extend below the angle of the jaw. 

The formation of a ranula may be rapid when due to a sudden 
obstruction and is accompanied by pain, tenderness and swelling 
over the affected gland. Severe pain may come on while eating, 
denoting a sudden blocking of the duct. 

In the chronic formation there is a gradually increasing 
tumor. 

Salivary calculi are objects composed of lime salts and organic 
substances that are more frequently found in the submaxillary 



1 88 MINOR SURGERY. 

duct. At first it is small and painless, though as the size in- 
creases there is tenderness, difficulty in speaking and mastica- 
tion. 

The stone can be detected with the finger through the wall of 
the duct or it may excite the formation of a ranula. Pus forms 
and is discharged into the mouth or through a sinus extending 
through the skin under the jaw. 

There is considerable pain and a dirty discharge. At times the 
calculi only cause a slight degree of chronic inflammation, and 
the walls of the duct become indurated and suppuration does not 
occur. The calculi may escape notice unless a needle is made to 
penetrate the center of the small swelling. 

Treatment. — Recent cases of ranula may be cured by the 
excision of a small part of the cyst wall and the cavity swabbed 
with a solution of Nitrate of silver, twenty grains to the ounce 
of water. This can be done without pain under local anaesthesia. 
Incision and allowing the albuminous-like fluid to escape is use- 
less, as is also the injection of Iodine or Carbolic acid. 

Other cases require excision, which can, as a rule, be done 
through the mouth. General anaesthesia and a good light are 
required. The tongue is protruded, raised to one side and the 
cyst dissected out without puncturing the sac, care being taken 
to remove the entire wall, for if a small portion is left a fistula 
might result. Another method is to empty the cyst and then 
distend the cavity with a piece of sponge, gauze or cotton so as 
to better define its limit and make the excision easier. 

Calculi are best removed by incising the duct in a normal 
direction and with the use of fine-pointed forceps or a curette. 
This operation can ordinarily be done with the aid of Cocaine or 
Kucaine. 

The principal remedies are Thuja, Mercury, Calcarea carb. 
and Sulphur. The patient should have a selected diet. 

ALVEOLAR ABSCESS OR GUM BOIL. 

This affection usually begins in the socket of a carious tooth. 
When superficial it gives rise to few external symptoms, but 
when located at the root of the tooth there are active symptoms 



CANCRUM ORIS OR NOMA. 1 89 

of severe throbbing pain, swelling of the cheek of the corre- 
sponding side and protrusion of the tooth from the thickening of 
the peridental tissues. When the molar teeth are involved the 
abscess may penetrate the tissues of the face and leave a sinus or 
scar. When the lateral incisors are affected the pus may spread 
posteriorly between the layers of the hard palate, or anteriorly 
in the direction of the nose, into which it opens. 

Necrosis of the maxilla and pyaemia are rare complications. 

Treatment. — Poultices must never be applied to the cheek. 
A raisin or date, split and the seed removed, heated in an oven 
and applied to the gum, will relieve pain and limit the inflamma- 
tion. Hot water, as hot as can be borne, held in the mouth, has 
the same effect. 

Painting the gums with a ten per cent, solution of Cocaine is of 
use in mild cases. If these measures are not effective, it will be 
necessary to incise the gum and try and irrigate the pus cavity 
with Peroxide of hydrogen. It is often wise to send the patient 
to a dentist. 

Belladonna, Mercurius and Plantago are useful in the first 
stages; Silicea, Hepar sulph., Calc. carb. and Staphysagria later 
in the disease. 

CANCRUM ORIS OR NOMA. 

This condition, very often seen in poorly nourished children is 
a phagedenic ulceration that commences as a dark gangrenous 
looking spot in the cheek or corner of the mouth. The progress 
of the disease is characterized by extensive and rapid destruction 
of the tissues and severe constitutional symptoms. The strepto- 
cocci have been found in noma. 

The treatment may be divided into surgical, medical, and 
mechanical. Every particle of the indurated, friable tissue must 
be extirpated. For this purpose general anaesthesia and the 
sharp spoon curette is preferred; or, it may be accomplished by 
thorough cauterization with the actual cautery without regard to 
possible deformity, for the ugly looking scar can be somewhat 
reduced by plastic operations. As the condition is prone to 
recur at intervals until the patient is restored to health, it may 



190 MINOR SURGERY. 

be necessary to repeat the operative treatment promptly to save 
life. 

The mechanical treatment consists in keeping the buccal 
cavity on the affected side, as well as the excavation, well packed 
with a deodorizing and antiseptic dressing, with the head so in- 
clined that the saliva may dribble out of the mouth, the patient 
being reminded to breathe through the nostrils. 

Hydrogen peroxide is a useful cleansing agent and may be fol- 
lowed with tampons of sterile gauze soaked in a solution of Oil 
of Cassia, two to four minims; Oil of Gaultheria, five minims 
and one-half drachm of Hydrastis. 

The dressings should be changed four or five times a day at 
first and less often as the healing process develops. 

Relapses are to be watched for. 

The medical treatment should be directed to the improvement 
of the nutrition and the giving of stimulants if necessary. Mer- 
cury, Carboveg., Arsenic, Hydrastis, Staphysagria are indicated. 

THE EXTRACTION OF TEETH. 

The instruments employed to extract teeth are of various 
shapes, though for the general practitioner two forceps are all 
that are really necessary; one for the upper and one for the lower 
jaw. 

The patient should be seated in a comfortable chair which may 
be very slightly tilted backwards. The head should not be 
pressed backwards and the neck stretched, especially when an 
anaesthetic is given. If nitrous oxide gas or gas and ether are 
given a mouth gag may be adjusted. The injection of a few 
drops of a freshly prepared four per cent, solution of Cocaine 
into the tooth socket will tend to prevent pain. 

To extract teeth from the left side of the lower jaw the 
operator should stand on the left side of the patient, with the side 
of the left thigh pressing against the arm of the chair. 

To extract teeth from the right side and interior portion of the 
lower jaw the operator should stand behind the patient on a 
slight elevation. 

To extract teeth from the upper jaw the operator should stand 



THE EXTRACTION OF TEETH. 191 

on the right front of the patient. The operator's left hand and 
arm encircle the patient's head and control the tongue, lips 
and cheeks. 

The forceps should first be driven well down towards the root 
and a firm grip taken. With the upper teeth extractive force is 
in the outward direction at once and not inwards to begin with. 
A tooth should not be ' ' rocked ' ' from side to side. With the 
lower teeth the force is applied in an outward, upward and 
slightly forward direction. The upper front teeth are grasped 
firmly and slightly rotated. The lower front teeth are well 
gripped and easily lifted from their sockets. 

Accidents from Extraction. — (a) Hemorrhage: This has 
proved fatal, though in ordinary cases the bleeding soon stops. 
If the bleeding persists the cavity should be thoroughly cleansed 
of bloodclots and a piece of ice put into it. If this does not check 
the oozing insert a small cotton pad soaked in a saturated solution 
of tannic acid or alum or persulphate of iron. This pad should 
be packed firmly into the socket and reach its uppermost part. If 
the pad is ineffective the fine point of a Paquelin cautery iron is 
useful. Excellent results have been obtained from a mixture of 
one part Chloroform with fifty parts water for rapidly arresting 
hemorrhage after tooth extraction. A simple method is to dip 
the roots of the extracted tooth in powdered alum or tannin and 
press it back to place. It can be removed later when all danger 
is past, or if absolutely necessary it might be allowed to re- 
main on the principle that a live patient with a bad tooth is 
better than a dead one without a tooth. 

( b) Dislocation or fracture of lower jaw. 

(c) Fracture of the opposing tooth. 

(d) Fracture of the tooth extracted. 

(e) Extraction of healthy teeth by mistake. 

(/) Forcing a tooth into the antrum of Highmore. 

(g) Tearing of the alveolar process. 

(h) Injury to the inferior dental nerve. 

( i ) Dropping foreign bodies into the larynx. 



192 MINOR SURGERY. 



WOUNDS OF THE TONGUE. 

Wounds made by the teeth and foreign bodies are the com- 
monest injuries to the tongue. The most serious result of the 
tongue wound is hemorrhage, and several fatal cases have been 
reported. Severe bites are more frequently noticed in epileptics 
and in women who suffer from puerperal eclampsia, also from 
falling on the chin while the tongue is partially protruded. 
Compound fractures of the lower jaw are productive of extensive 
laceration of the tongue. A case is reported of a man engaged 
in a fight with his son who choked him, and when his tongue 
protruded seized it with his teeth, making a severe wound. 

Treatment. — In persons subject to fits care must be taken to 
prevent self injury. A folded handkerchief, a knife handle, a 
piece of wood or metal should be inserted between the jaws. An 
interdental splint is advised, for epileptics to be worn at night. 
This is of importance, for several of this class have been found 
dead in the morning, having bitten the tongue while in an attack 
and caused fatal bleeding. 

All cases of tongue wounds demand that an attempt be made 
to approximate the edges and that sutures be introduced. If 
there is no displacement of the partially severed tip it is not 
necessary always to sew it in place. A local or general anaes- 
thetic may be required. The wound should be cleaned of clots 
and bleeding points ligated. Sutures of horse hair or fine catgut 
may be used and left until they work out or the catgut becomes 
absorbed. Only liquid food is to be given for a few days, and 
should the wound be an extensive one the patient may be 
nourished by rectal enemata. Several times a day the mouth 
should be washed out with Permanganate of potash solution 1 to 
3000. Sometimes it is necessary if the case is not seen early to 
trim the wound edges with scissors before bringing the edges 
into apposition. 

Hemorrhage due to injuries of the tongue require prompt 
measures for its control. If the wound be in the anterior part 
this is not hard to do, but if the wound is located far back a more 
serious task is before one. As in all cases of hemorrhage the 



FOREIGN BODIES IN THE TONGUE. 1 93 

finger can apply pressure the easiest, and this should be kept up 
until arrangements are made for the permanent control. A by- 
stander or the intelligent patient can be instructed to perform 
this duty. The individual should then be put on a table where 
there is good light and given chloroform, if it can be taken. Sepa- 
rate the jaws well with a mouth gag, pass two strong silk liga : 
tures through the tip, one on either side, and draw the organ 
well out. These measures will permit the surgeon to examine 
the wound closely and: treat the bleeding effectively. If the 
spurting point can be seen the vessel should be ligated with fine 
silk or catgut. If there is a deep or punctured wound and the 
blood flows out generously and no bleeding point can be found, 
the wound must be enlarged until the vessel can be caught and 
tied. Fortunately the larger arteries are deeply located and can- 
not be injured by a superficial cut, though it may be necessary to 
follow up a punctured wound to some depth. If one is certain 
the hemorrhage is not due to divided arteries but is due to injured 
veins, or there is general oozing, the blood clots should be turned 
out, deep sutures passed and the wound edges brought together. 
This procedure will stop the bleeding. In very severe injuries, 
and where there is dangerous hemorrhage, ligation of the lingual 
artery in the neck will be required. If it is really impossible to 
discover the source of the hemorrhage or the wound is far back 
on the tongue and has injured the tonsil and its artery, it may 
be necessary to tie off the external or common carotid artery. 

FOREIGN BODIES IN THE TONGUE. 

Bullets, needles, fish bones, pipe stems, pieces of metal and 
other foreign bodies have been found in the tongue. Rifle 
bullets of high velocity are more often fatal because of the severe 
laceration of the tongue and of the larger arteries in the neck. 
Bullets of low velocity cause frequent injuries and are not so 
severe in their effects. A bullet may drive a tooth before it or 
it may lodge in the tongue or pharyngeal wall. 

The treatment of foreign bodies in the tongue embraces their 
early removal. Occasionally the body may be so small that its 
presence is not suspected, and even if it were its small size pre- 
13 



194 MINOR SURGERY. 

vents defining the location. It becomes partial^ encysted, and 
the wound cannot heal. After a few days its presence may ex- 
cite secondary hemorrhage, which is, as a rule, repeated until 
the foreign body is removed. If no blood-vessel has been 
wounded inflammation may result from the presence of the 
object and an indurated tumor is formed. A sinus leading from 
the surface of the small swelling down to the foreign body is likely 
to intervene. Similar cases go on to pus formation, multiple 
sinuses form and become indolent. If the bod}- is small it may be 
expelled, though the usual course is for it to become encysted. 

Bullets, teeth and other objects should not be extracted with- 
out having present the means for controlling possible hemorrhage. 
The patient should be placed in a good light, anaesthetized, the 
jaws separated by the mouth gag, and the tongue drawn out by 
two strong silk threads passed through the tip. The sinuses, if 
present, should be examined with a probe and the object located. 
An incision is made down to it, and when withdrawn the surgeon 
must be prepared for a possible gush of blood. Hemorrhage is 
controlled, the walls of the small cavity curetted, cleansed and 
an effort made to approximate the wound edge with fine catgut 
or horse hair. The mouth should afterward be frequently 
irrigated with a Permanganate of potash solution, i to 3000, and 
the patient put on a liquid diet for a few da}^s, or else fed per 
rectum. 

STINGS AND BITES OF THE TONGUE. 

Stings of insects are rather common, while bites of reptiles are 
very rare; though cases are recorded where incautious handling 
of reptiles have resulted in the tongue being bitten. Bees, 
hornets and other stinging insects are conveyed to the mouth in 
food. Such cases have proved fatal within a very short time be- 
cause of the great blood and lymph supply of the tongue. The 
tongue may become enormously swollen and suffocation threaten. 
In most instances the inflammation is transitory and relief is ex- 
perienced. A hardened area will mark the location of the sting 
for weeks after. In some cases the individual after receiving 
the injury collapses, looses consciousness, and the respiration soon 
ceases. 



ADHERENT TONGUE OR TONGUE-TIE. 1 95 

Treatment. — The mouth should be very frequently washed 
with the Boric acid solution so as to neutralize the Formic acid 
which is the alkaloid of the poison. The injection into the af- 
fected area of a weak Ammonia solution is also effective. If 
there is acute oedema of the glottis following the swelling of the 
tongue tracheotomy is required to save life. 

When the tongue is enormously swollen and hangs out of the 
mouth, more active measures are necessary. Leeches should be ap- 
plied to the submaxillary regions. The bowels should be cleaned 
out and a liquid diet given when the patient can swallow. 
Astringent mouth washes and the application of Iodine and ice 
to the tongue, and blisters to the floor of the mouth, are advis- 
able. In those cases where there is difficulty in breathing and 
swallowing it may be necessary to incise the organ. This pro- 
cedure, as a rule, gives speedy relief and prevents the deep for- 
mation of pus. Two longitudinal incisions, one on either side of 
the middle line and about two-thirds of an inch from the raphe, 
are best. These penetrate to a depth of one-third of an inch. A 
sharp curved knife is best for the incisions, which are not serious 
unless the knife enters too deeply, while it is desirable to loose a 
moderate amount of blood. It is not safe to give a general 
anaesthetic to cases that require incisions, though ethyl chloride 
spray will lessen the pain of the cuts. 

ADHERENT TONGUE OR TONGUE-TIE. 

This condition may be either congenital or acquired. Children 
are born with the tip of the tongue bound down to the floor of 
the mouth because of a very short fraenum and folds of 
mucous membrane on each side of the fraenum. This is due to im- 
perfect development of the anterior portion of the organ. In 
some cases there has simply been tardy development and the 
fraenum will lengthen as the child grows. It is this latter condi- 
tion that has given rise to the idea that all cases of short fraenum 
are subjects for operation. The real persisting congenital cases 
are so extremely rare that the ordinary physician never sees a 
case. There can be no doubt but that the operations for so-called 
tongue-tie have been altogether too frequently performed and 



196 MINOR SURGERY. 

as a result accidents occur, such as fatal hemorrhage, septic 
ulcers, that on healing, leave a puckered scar and so increase 
the original deformity. The division of the cord also allows the 
tongue to fall back into the pharynx, causing ' ' tongue swallow- 
ing ' ' and suffocation. Several cases of fatal hemorrhage are on 
record due to division of the fraenum. 

Although congenital cases are rare, those that do present re- 
quire operation. This should be done in a proper manner after a 
careful consideration of the case. The finger-nail should not be 
used in making the division. Clean scissors are the best instru- 
ments. The division of the fraenum is best accomplished by 
placing the index and second finger of the left hand beneath the 
anterior part of the tongue, one on either side of the fraenum, 
and lifting up the tip of the organ tighten the cord to be 
divided. A tiny snip is made through the mucous membrane of 
the tense band close to the inner surface of the lower jaw. Care 
should be taken to make only a minute cut and that the inser- 
tions of the geniohyo-glossi are not divided. Neither should the 
tongue be stripped up by the fingers. 

The accidents following an excessive division of the fraenum 
are hemorrhage and tongue swallowing. Hemorrhage is treated 
by passing a needle threaded with silk through the tip of the 
tongue and drawing it forwards and upwards. If there be but slight 
oozing, a little Aristol powder can be sprinkled on and a narrow 
strip of gauze inserted. The thread through the tongue and the 
end of the strip of gauze are fastened against the chin by adhesive 
plaster, the tongue being pressed against the gauze pressure is 
made on the bleeding point. If these measures fail to control the 
oozing it may be necessary to call assistance. Give Chloroform 
to a slight degree, clear the mouth of blood clots and pass a fine 
ligature of cat-gut about the bleeding point. One should be 
gentle, as the delicate tissue is apt to tear further and defeat the 
aim in view. 

Acquired tongue-tie is due to diseased conditions, more often to 
ulceration and sloughing and to caustics coming in contact with 
the mucous membranes. Gun-shot wounds have been known to 
cause tongue-tie. Adhesions form between ulcerating surfaces 
and bind the tongue down so it becomes fixed and impairment of 



ACUTE ABSCESS OF THE TONGUE. 1 97 

function and motion results. The treatment consists in dividing 
the adhesions with scissors or the galvano-cautery. Prompt 
measures must be instituted to control possible bleeding and care 
taken to prevent the recurrence of adhesions. 

ACUTE ABSCESS OF THE TONGUE. 

This condition is caused by pathological changes, injuries, 
foreign bodies, stings of insects and blows under the chin. An 
indurated, localized swelling is first noted. Pus may form and 
the abscess burst into the mouth. The process is very painful, 
though the patient is able to swallow and may have some difficulty 
in breathing. Staphylococci are found in the broken down tissue. 
If seen before the abscess breaks Cocaine can be applied and a 
painless puncture or incision will liberate the contained pus if 
present, or relieve tension and prevent further suppuration. Ab- 
scess has been seen on the dorsum of the tongue. If the abscess 
is below the tongue the member is elevated and pushed back. 
Care must be taken not to use the knife too freely because of the 
possibility of injuring blood vessels. Blunt-pointed forceps are 
the better instruments in such a case. If there is considerable 
suppuration it may be advisable to make a counter incision be- 
low the chin and insert a drainage tube to the cavity from the 
outside. By this means the abscess can be well cleansed. For- 
tunately, the tongue heals readily after injuries and operations 
if kept clean. The mouth should be cleansed with a Perman- 
ganate of potash solution and the cavity with Hydrogen peroxide 
and packed with a strip of gauze. For therapeutics see Abscess. 

BURNS AND SCALDS OF THE TONGUE. 

Slight burns of the tongue are commonly met with in both the 
young and adults and are frequently due to the taking of too hot 
food and liquids in the mouth. This class of burns heals readily, 
though for a short time the burned area is painful, rather tender, 
redder and smoother in appearance than the rest of the tongue. 
Possibly slight excoriations may be present. As a rule, these 
trivial burns do not require treatment, though if the pain be 
severe a four per cent. Cocaine solution will relieve and a mouth 
wash of Boric acid, twenty grains to the ounce of water, is effect- 



I98 MINOR SURGKRY. 

ive. Sucking bits of ice is also of value. Borax and honey is a 
good application. After a few hours have elapsed the pain and 
tenderness disappear and the burned area becomes normal in ap- 
pearance. 

Severe burns of the tongue are those due to contact with 
chemicals like mineral acids and the caustic alkalies. In these 
cases the back part of the mouth, tongue and fauces are princi- 
pally involved. Individuals who aim to destroy life with poisons 
often burn the tongue and throat. The effects produced by 
different agents vary. Corrosive sublimate produces a white and 
shriveled condition, with great enlargement of the papillae. Sul- 
phuric acid produces a white and glazed condition that in a short 
time turns gray or brownish-gray. The surface is excoriated 
and the organ swollen. Nitric acid produces a general swelling, 
a citron color, and the mucous membrane is soft and easily peels 
off. Hydrochloric acid produces a swollen • and dry tongue. 
Oxalic acid produces a swollen tongue, which is covered with a 
thick white coating. Carbolic acid produces a white and hard 
mucous membrane. Tincture of cantharides produces swelling 
and excoriation. Potash and soda produce a softening of the 
mucous membrane which is easily removed. Caustics produce a 
bluish-red or yellowish-red color, while ammonia changes the 
color to white. These discolor ations of the organ cannot be 
said to be characteristic except in corrosive sublimate poisoning. 
The condition is influenced, of course, by the time the chemical 
is in contact with the tissues. 

Scalds of the tongue and the ■ buccal cavity are of frequent 
occurrence and more often seen in children. A single drop 
of scalding water can do a great deal of harm, though the 
chief danger is to the air passages due to the inhalation of steam. 
Scalds produce a swelling of the tongue which soon becomes very 
painful and tender. The taking of either liquid or solid food is 
difficult. The papillae are smoothed, the surface becomes red- 
dened and vesicles may form. If the scald be slight, the un- 
pleasant symptoms soon pass off and the individual is able to 
swallow again in a few hours. It is not necessary to puncture 
the blisters that form, as experience has shown that no direct 
good results from so doing. The irritation to the interior of the 



INTUBATION OF THE LARYNX. 1 99 

mouth hardly ever requires treatment in slight scalds, though 
mouth washes of Boric acid solution are of much value. The 
action of the acids must be antidoted by alkalies, and the action 
of strong alkalies by dilute acids. Alcohol is the latest and best 
antidote for the local and constitutional effects of carbolic acid. 
If the patient is unable to swallow, feeding by the rectum or 
stomach- tube may be necessary. The mouth should be kept 
clean, and an attempt made to prevent the formation of ad- 
hesions. 

Burns due to lighted cigars are often slight, though chronic 
ulcers have resulted and cases of malignant disease have been 
reported following upon such injuries. Butlin reports an inter- 
esting case of a woman who put an ounce of gunpowder into her 
mouth and set fire to it. On entering the room, which was full 
of smoke, the woman was found rolling upon the floor. Blood 
was oozing from her mouth and the tongue and roof of her mouth 
were blackened. She died the following day. For therapeutics 
see Burns and Scalds. 

INTUBATION OF THE LARYNX. 

Intubation is a term given to the operation of introducing a 
tube through the mouth into the larynx when required for the 
maintenance of the respiratory function. Intubation of the 
larynx is not easy to perform, and requires a considerable amount 
of manual dexterity and practice to do it properly. The opera- 
tion is not indicated in every case of alarming dyspnoea, and the 
conditions requiring it have to be differentiated from conditions 
that call for tracheotomy. The really special field and useful- 
ness of intubation is in cases of diphtheria or any membranous 
obstruction of the larynx; the presence of papillomatous growths 
in children, and cicatricial stenosis of the larynx in the adult. 
Intubation is contraindicated when foreign bodies imbedded in 
the larynx cause difficult respiration; in pharyngeal and retro- 
pharyngeal abscesses that impede respiration; in oedema of the 
larynx; in great enlargement of the tonsils and uvula. 

Since the introduction of antitoxine this operation is not so fre- 
quently demanded, though when the unfavorable symptoms are 
becoming more pronounced, it is very important that relief be 



200 MINOR SURGERY. 

given early, and if this is done many bad results will be avoided. 
When the operation is properly performed it in no way compro- 
mises the case or adds to the danger, but quickly relieves suffer- 
ing and prevents exhaustion. It is a good plan to have at hand 
in all cases of intended intubation instruments for the perform- 
ance of tracheotomy. The reason is apparent. 

Technique. — It is wise when practicable to gain a knowledge 
of the landmarks of the larynx by practicing the operation upon 
the cadaver. This will aid in intubating the adult larynx, but 
will be of little help in acquiring the operative technique in chil- 
dren. The adult epiglottis is prominent, while in young children 
it is very small. The O'Dwyer instruments are largely used. 
The set consists of several tubes appropriate for the age of the 
patient, as indicated by an accompanying scale, a mouth gag, 
tongue depressor, an introducer for passing the tube into place, 
and an extractor. Intubation in adults is easily performed with 
the aid of the laryngeal mirror. The patient holds the tongue 
drawn well forward with a napkin held between the thumb and 
forefinger. The operator sits in front. The tube held by the 
introducer is passed in the median line with its point held close 
to the anterior wall. The reflected light and mirror enable the 
operator to guide the tube over the epiglottis, and its point will 
pass into the larynx. Hastily dropping the laryngeal mirror 
from the left hand the operator passes the forefinger down upon 
the head of the tube and gently presses it into position, the tube 
being released from the introducer by a movement of the right 
thumb. Experienced workers in the larynx will perforin this 
operation quickly, while those not versed in handling laryngeal 
instruments will work at some disadvantage. For the inex- 
perienced it will be better not to use the mirror but to introduce 
the forefinger of the left hand, and when the epiglottis is drawn 
forward pass the tube in the median line and slip it into the 
larynx. It is important to hug the anterior wall with the point 
of the tube and keep in the median line. 

When a child is to be intubated it is best to hold it upright in 
the lap of the nurse supported closely against the left chest with 
the head resting upon the shoulder. A straight back chair is 
preferable. The child, if very small, can be wrapped in a sheet 



INTUBATION OF THE LARNYX. 201 

or blanket which is fastened tightly with pins so that the little 
patient will be easily controlled. The hands and arms of the 
child are crossed in front and the nurse should grasp the wrists, 
the left wrist with the right hand, and the right wrist with her 
left hand. The head is held firmly by a second assistant and a 
mouth gag is inserted in the left angle of the mouth well back 
between the teeth and widely opened. The operator in the mean- 
time has selected a proper tube, threaded it with silk, making a 
loop about fifteen inches" in length. It is then attached to the 
introducer. Of course instruments should be sterilized when 
there is time. With the gag in place, the operator, who should 
stand in front of the patient, grasps the handle of the introducer 
and the attached tube, the loop of silk being thrown over the 
little finger of the left hand. The index finger of the same hand is 
introduced into the larynx followed immediately by the tube, which 
must be kept in the median line, hugging closely the anterior 
wall. The epiglottis is drawn forward with the forefinger and 
the end of the tube is gently guided over it, but under the tip of 
the finger into the larynx by quickly elevating the right hand, 
holding the elevator which allows the tube to be passed down at 
a right angle. At the same moment the tube is released from the 
introducer by a movement of the thumb. The left index finger 
is placed upon the head of the tube and makes slight pressure 
until it is in position, wmile the introducer is removed with the 
right hand. If the handle of the introducer is not elevated 
abruptly as mentioned, the tube will pass over into the oesopha- 
gus. The operation should be characterized by gentleness, and a 
prolonged attempt in case of failure at first should be avoided. 
It is better to make numerous brief attempts, and between them 
give the patient a chance to recover his breath. If the tube is 
not obstructed with membrane its entrance into the larynx will 
be denoted by easy respiration and violent coughing. A good 
test to prove whether or not the tube is in proper place is to give 
the child a drink of water from a glass. If the tube is in the 
larynx the water will excite violent coughing, if in the oesopha- 
gus the labored breathing will not be relieved, neither -will there 
be coughing, and there will be shortening of the thread as the 
tube drops toward the stomach. The gag is removed and the loop 



202 MINOR SURGERY. 

of thread passed about the patient's ear. In a few minutes, if 
the patient's breathing is easier, the gag is reinserted, the cord 
divided, the left index finger is introduced and presses upon 
the head of the tube while the cord is withdrawn. The person 
holding the child should never release the child's hands until the 
string is removed. 

In some cases the membrane is crowded down ahead of the 
tube and no relief is experienced. Then the patient is instructed 
or excited to cough violently with the prospect of expelling the 
membrane. Giving the patient a little water or liquor will some- 
times excite violent coughing. Special forceps are also used to 
clear away the membrane. Tracheotomy may even be neces- 
sary. Syncope caused by intubation should be treated by 
repeated blows upon the back and chest, the child being 
held with the head downward. Should total obstruction 
of the tube occur the child will die in a few minutes unless 
the tube is expelled. The after treatment of intubated cases in- 
cludes rest and nourishment. A liquid diet consisting of milk, 
beef juice, liquid peptonoids and soups is best. In feeding 
children, while the tube is still in the larynx, the patient should 
lie on the abdomen face down. Another posture is to place the 
child head downward on an inclined plane at an angle of from 45 
to 90 degrees. The child is held on its back in the arms of the 
nurse, the feet elevated, and the head left to hang over the arm. 
Then it may take the feeding bottle, a glass tube or a spoon. 
The exact posture will be found after repeated feedings in differ- 
ent inclined planes. 

The tube, in ordinary cases, is left in place four or five days. 
In special cases it can be worn for several weeks. The technique 
for extracting the tube is very similar to its introduction. The 
gag is used; the index finger locates the head of the tube; the 
extractor held in the right hand is guided into the tube; the jaws 
of the extractor are separated and grasping the tube firmly it is 
removed by the right hand. It is a good plan to remain near the 
patient for an hour or so after the extraction of the tube for fear 
of returning dyspnoea which will require another operation. 



TRACHEOTOMY. 203 



TRACHEOTOMY. 

The trachea requires to be opened from the outside when there 
is acute obstruction due to disease or to the presence of a foreign 
body which prevents air entering the lungs. Diphtheria, mem- 
branous croup, larjmgeal and pharyngeal oedema are some of the 
morbid conditions which may demand the operation . Tracheotomy 
is performed as a preliminary operation for surgical measures to 
be taken about the throat. It is a mistake to wait until the pa- 
tient is nearly asphyxiated before this operation is performed. 

Many deaths have resulted because of undue delay. In grave 
emergencies the physician may even use his pocket knife to open 
the trachea. A hasty vertical cut through the skin from the thy- 
roid notch to the lower edge of the cricoid cartilage followed by 
a deep incision with the knife-point foremost into the crico-thy- 
roid membrane will allow the inhalation of air. The edges of the 
wound can be held apart with two hair-pins bent so the rounded 
tops may be used as blunt retractors, until the special tube can be 
procured and placed in position. A stout silk ligature passed 
through the skin and crico-thyroid membrane at each side of the 
wound and the ends tied at the back of the patient's neck also 
serve as retractors. This operation in emergencies can be per- 
formed without an anaesthetic, the patient being held with force, 
or, if the individual is unconscious it w T ill not be necessay. Arti- 
ficial respiration should be employed at once, if indicated. When 
the operation is not so hurriedly required there is usually time to 
make the necessary preparations. 

Tracheotomy-tubes of various shapes and sizes are made of hard 
and soft rubber, aluminum and silver. The latter is more easily 
sterilized. This instrument consists of an inner and an outer 
curved tube which can be taken apart. A flange is attached 
to the outer end of the outer tube, being provided with slits 
for the insertion of tapes which are to be tied about the neck and 
keep the instrument in its proper position. It is wise to have on 
hand, in addition to the tube, a short grooved director, artery 
forceps, two pair of rat- tooth forceps, two sharp pointed knives, 
a tenaculum, a tracheal dilator and forceps. The patient lies in 



204 MINOR SURGERY. 

the recumbent position with the shoulders raised by a pad and 
the head thrown back. An assistant holds the head firmly in a 
straight line with the body. The trachea can be opened at any 
point between the cricoid cartilage and the upper border of the 
sternum, the distance varying from 2^ to 3 inches in the adult 
and ij4 to 2% inches in a child under ten years of age. 

Its course is somewhat obliquely backward and downward, the 
upper portion is nearly subcutaneous, while the lower part is 
deeply situated as it passes behind the sternum. The isthmus of 
the thyroid gland crosses at the upper part, and an anastomosing 
branch of the two inferior thyroid arteries crosses a trifle below 
the lower border of the isthmus. The thyroid veins cover the 
anterior lower part. Anatomical peculiarities are frequently 
found in this region and add to the normal risk of the operation. 
Of these anomalies the more important is when a branch is given 
off of the aortic arch and ascends along the anterior surface of 
the trachea in the median line. The left brachio-cephalic vein 
may cross the trachea well above the sternum. The surgeon 
should bear these facts in mind, and when the patient is anaes- 
thetized and the neck prepared for the incision he stands at the 
patient's right side. Some operators prefer to stand at the head 
of the patient, as it is easier to keep the incisions exactly in the 
median line. The operator locates with his finger the hyoid 
bone, thyroid and cricoid cartilages, and makes an incision 
in the median line of the neck from one-half to two inches in 
length according to the size of the patient. When the skin is 
divided the superficial anterior jugular veins are encountered. 
These must be carefully drawn aside and the fascia picked up 
and divided upon the director. Two assistants should hold the 
sides of the incision apart during the dissection. This must be 
done without disturbing the relations of the parts. As the wound 
increases in depth one should not make his incisions too short so 
that they become funnel-shaped. The deep fascia when exposed 
is picked up and divided, and the deeper veins lying in the line 
of the wound are carefully displaced or else divided between two 
ligatures. Some of the smaller ones need not be tied, as the 
bleeding will soon cease after the trachea is opened, and the 
venous congestion relieved by the admission of air to the lungs. 



TRACHEOTOMY. 205 

The sterno-hyoid and sternothyroid muscles are next sought for 
and separated. The isthmus of the thyroid will now be exposed 
and is drawn upward with a blunt hook. The trachea, yellow- 
ish-white in color, can now be seen. The fascia covering it is 
divided with the knife and director, and the trachea laid bare. 
Three or four rings of the trachea are uncovered, a sharp- 
pointed hook is introduced into one of the tracheal rings at a 
little to one side of the median line so that the tube may be lifted 
slightly and made more prominent, thus making the point for in- 
cision more pronounced. A narrow knife is introduced and 
divides the structure from below upward from one-half to three- 
fourths of an inch in length, the opening being sufficiently large 
to admit the tube readily. The sharp-pointed knife must be pre- 
vented from making a too deep cut by holding it close to the 



Fig. 48. Parts exposed in tracheotomy. 

point. It is important that the incision is made in the median 
line, for if the trachea be opened to one side the wound will not 
heal as well and the tracheotomy tube may also injure the mucous 
membrane of the trachea. After the trachea has been punctured 
the wound can be enlarged by scissors or gentle sawing motions 
of the knife. As soon as the trachea is opened there is a gush of 
air from the wound mixed with blood or membrane. This should 
be wiped away, the knife being retained in the trachea as a guide 
until a tracheal dilator can be introduced. A self -retaining dila- 
tor is best. The trachea should be cleared of blood and mem- 



206 MINOR SURGERY. 

brane if present by a cotton swab fixed to a probe. If the opera- 
tion was performed on account of a foreign body, the finger 
should be passed upward and downward in the trachea, and the 
throat should be examined through the mouth. If the body is 
not found, and it is likely that the object has passed further 
down, the foot end of the table should be elevated and the body 
inclined at least thirty degrees. Efforts at coughing are made 
and the wound carefully watched, so that should the foreign sub- 
stance appear it can be quickly seized and removed. Rubber 
tubing and a strong rubber bulb are useful to remove, by suction, 
adherent membranes. 

The tube may be inserted into the trachea as far as it will go. 
If a tracheal dilator is not at hand a quick way to hold open the 
tracheal wound is to insert the handle of the knife and turn it at 
right angles to the long axis of the trachea. A properly fitting 
'sterilized tube is placed in position, first placing a pad of gauze, 
slit to receive the tube, between the skin and metal tube and so 
avoid irritation of the tissues. It is a good plan to introduce a 
suture or two through the skin both above and below the tube as 
healing progresses. It is also advisable to place over the exter- 
nal opening of the tracheotomy tube apiece of gauze or sponge 
soaked in warm water or saline solution so that the inspired air 
will be moistened. 

After Treatment. With the tube in the correct position 
phonation is impossible, and if the individual should make a vocal 
sound of any kind it indicates that the tube has slipped out of the 
tracheal opening. If this accident occurs the tube must be re- 
placed as soon as possible. 

The sick room should be kept at a temperature of about 75 ° F., 
and the moist compress frequently changed for the first few days 
after the operation. The tube must be watched that it does not 
become obstructed by mucus, blood, pus or membranes. If there 
is an accumulation of any kind it may be cleansed by removing 
the inner tube. Coughing, a rattling sound and distressed 
breathing are symptoms of obstruction. If there is danger of 
asphyxia from an obstructed tube the tube must be removed 
instantly, the wound edges separated and artificial respiration 



EXCISION OF THE TONSILS. 207 

practiced until the tube can be cleansed and reinserted. The 
lumen of the trachea should also be cleansed. 

Metal tracheotomy tubes are provided with an inner tube 
which can be removed, boiled in a soda solution and rinsed in 
sterile water twice every twenty-four hours. Daily inspection of 
the wound is necessary and if the patient goes on to recovery 
the outer opening of the tube can be temporarily plugged with 
the finger to ascertain whether or not the original obstruction 
still exists. If not, and healing is well established, the tube may 
be removed and the wound allowed to heal by granulation with- 
out sutures, drainage being provided with gauze strips. At times 
exuberant granulations form and cause obstruction before the 
tube has been removed. Nitrate of silver fused upon a probe is 
required to control the unhealthy granulations. The actual stick 
of the silver nitrate should not be used for fear of its dropping 
out of reach into the opening. 

FOREIGN BODIES IN THE EAR. 

The removal of foreign bodies from the ear is best accomplished 
with the aid of slender forceps and light from a head reflector. 
An aural speculum helps to procure a good view of the object. 
In emergencies the person's head should be held with the face 
down and the ear syringed out thoroughly. Gentle efforts may 
be made with a crochet needle, a hairpin, or an ear spoon. 

As the outer passage of the ear is very delicate extreme gentle- 
ness should characterize the efforts to remove the offending 
object. If live insects get into the meatus sweet oil or glycer- 
ine should be dropped in and then syringed out with w T arm 
water. A simple method is to turn the ear at once to a bright 
light so as to tempt the insect to come out on account of the at- 
traction which light has for nearly all insects. 

EXCISION OF THE TONSILS. 

Enlarged tonsils very often require removal. The Mathieu 
and the Mackenzie tonsillotome are the favored instruments. 
The patient is placed in a good natural light, or the throat can 



208 MINOR SURGERY. 

be illuminated by a head reflector. Small children have to be 
anaesthetized to be controlled, while young adults not infre- 
quently will sit quiet and allow both tonsils removed. The pain 
is not at all severe and is short-lived. Swabbing the tonsils with 
a four per cent, cocaine solution is practiced. The injection of 
the same solution into the tonsils tends to bring on secondary 
hemorrhage. The fenestrated portion of the instrument is car- 
ried around the tonsil back to the border of the pillars. The 
shaft attached to the blade is driven home by pressure of the 
thumb, and the excised portion comes away with the instruments. 
Both tonsils can be removed in a few seconds. At times the 
tonsil and pillars become adherent, and when this occurs the ad- 
hesions must be separated by the probe before they can be excised. 
There have been numerous cases of severe and even fatal hemor- 
rhage following tonsillotomy, and before operating it is always 
wise to enquire if the patient is a " bleeder. ' ' In such a case one 
is justified in refusing to operate with a knife, though the cold 
wire snare or the galvano-cautery snare may be used. Bleeding 
after the operation can be treated by sucking small bits of ice or 
spraying the raw surface with a five per cent, solution of chloro- 
form. Pressure applied on the tonsil and under the angle of the 
jaw over the gland is useful, as is searing of the cut surface with 
the galvano-cautery. It may be necessary to seek out the bleed- 
ing point and twist it or apply a ligature. Ligation of the ex- 
ternal carotid artery is a last resort. The injection of a solution 
of suprarenal extract, one drachm to two ounces of water, pre- 
vious to the operation will in many cases prevent bleeding. The 
patient should be limited to a liquid diet for a day or two after 
amputating the tonsils. 

ABSCESS OF THE SALIVARY GLANDS. 

The submaxillary and the parotid glands are the ones usually 
the seat of suppuration. The infection may extend from the 
mouth or may be due to calculi in the salivary ducts. Suppura- 
tion occurring during parotitis or mumps is not infrequently ob- 
served. Another cause is general sepsis. 

The symptoms consist of pain, heat, redness and swelling in 



ABSCESS OF THE SALIVARY GEANDS. 209 

the affected region, chill and fever, headache and loss of appetite. 
Motion of the jaws is accompanied by pain, which runs into the 
ear. The symptoms increase in intensity as the suppurative pro- 
cess extends, and the overlying tissues become more congested 
and discolored. 

Treatment. — It is important to make a correct diagnosis 
early. Sarcoma, aneurism and benign tumors are to thought of, 
though an aspirating needle may be of much service if there be 
any doubt as to the real 'Condition. Unless the pus points super- 
ficially and can be easily liberated a general anaesthetic will be 
required, as the operation is an extremely painful one. Anti- 
septic precautions are to be enforced, and the surrounding parts 
protected with sterilized towels. It is a good plan to plug the 
patient's ear on the affected side with a strip of gauze or cotton 
so that neither the wound discharges nor antiseptic solutions may 
enter the auditory meatus. If the submaxillary gland be affected 
there is often difficulty in opening the mouth, and the accu- 
mulation of mucus and saliva in the mouth as well as a 
tendency to respiratory failure adds to the responsibility of the 
person who administers the anaesthetic. If the inflammatory 
tumor is not very large a straight incision should be made at 
right angles with the jaw. If the swelling is extensive the in- 
cision must be in a wide arc, with the borders of the maxilla as 
the boundary. The wound edges should now be separated with 
sharp retractors, and the tissues divided down through the con- 
gested mass until the gland itself is opened. The field of the 
operation should be kept well sponged as the dissection progresses 
so that the surgeon will see clearly. 

When the gland is punctured one may be surprised to find only 
a drop or two of pus, though in all probability the whole gland 
is necrotic, and is the cause of the local and constitutional 
symptoms. Dressing forceps or artery forceps with closed jaws 
should enter the glandular substance, the jaws opened as the 
instrument is withdrawn, thus making an opening sufficient for 
good drainage. The gland is thoroughly curetted and irrigated. 
Strips of moist bichloride or plain gauze can be packed to the 
bottom of the cavity with dressing forceps. If kept clean the 
cavity will heal by granulation without further trouble. As 
14 



2IO MINOR SURGERY. 

salivary calculi are occasionally the cause of this affection it is a 
good plan to examine the salivary ducts under the tongue with 
the finger to ascertain if they are present. 

If the abscess is located in the parotid gland a vertical incision 
should be made through the skin and the wound edges separated 
by sharp retractors. With the field clearly exposed transverse 
incisions are carefully made until the gland is reached. The 
transverse cuts are made in order to avoid unnecessary laceration 
of fibers of the facial nerve that penetrate the gland from behind 
forward. 

The gland may be the site of multiple but small suppurating 
cavities that are divided by thickened bands of fascia. Each 
limiting wall must be broken down, the pus liberated and the 
necrotic tissue curetted away. 

The wound is irrigated with bichloride solution, i to 2000, 
wiped dry and packed with strips of wet gauze. If there is an 
inclination to hemorrhage dry gauze packing is indicated. This 
can be replaced in a few hours by wet gauze. When these sup- 
purative processes are neglected a true phlegmon occurs, and as a 
result we have a more complicated condition. It is even possible 
for the larger blood vessels of the neck to become involved, and 
fatal hemorrhage occur. The swelling may become so large 
that there is interference with breathing, because of pressure 
upon the trachea. In such cases a preliminary tracheotomy may 
have to be performed to save life. 

The medical treatment will be found in the chapter devoted to 
Abscess. 

CUT THROAT. 

Incised wounds of the front of the throat, inflicted with 
murderous or suicidal intent may cause death instantly from 
hemorrhage or from asphyxia due to the presence of large 
quantities of blood in the trachea. 

In self inflicted wounds the larger vessels of the sides of the 
neck very often escape injury, though the muscles, smaller ves- 
sels, trachea and oesophagus may be divided or entered. When 
the throat above the hyoid bone is cut the tongue is possibly in- 



CUT THROAT. 211 

jured and may fall back upon the epiglottis and suffocation re- 
sult unless the pressure is relieved. 

Treatment. — Hemorrhage must first be controlled tem- 
porarily, if need be with the fingers of the bystanders until the 
surgeon is prepared to arrest it permanently. The bleeding 
points can then be caught with hemostatic forceps and a ligature 
thrown about the divided vessel. 

If the larger veins have been injured pressure should be made 
on the proximal end to prevent air entering the circulation. 
The trachea should be cleaned of blood clots, artificial respiration 
resorted to when indicated and the edges of the tracheal wound 
held apart by retractors. Bent hair-pins serve as retractors in an 
emergency. When the bleeding is under control the wound 
should be well irrigated with bichloride solution, i to 2000, and 
partially sutured. Divided muscles are sewed with chromatized 
catgut and the nerves with fine silk. Hither silk or gut answer 
for the skin sutures. The wound in the trachea is left to heal by 
granulation and sutures are not placed in it or in the skin over it. 
If the oesophagus has been incised it is not absolutely necessary 
to place sutures, though if the wound can be approached without 
too much effort fine catgut stitches can be taken, but the needle 
must not enter the lumen of the canal. The skin directly over 
it must not be sutured. Strips of sterile gauze are inserted to 
provide for drainage and moist dressings applied. The head 
should be flexed upon the neck so as avoid tension of the reunited 
structures and this position maintained with the aid of crinoline 
or plaster of paris bandages. 

Would-be suicides must be watched and prevented from re- 
opening the wound by extension of the head. 

The intra-venous injection of saline solution will be required if 
there is much shock; also hypodermics of strychnine and brandy. 
The complications liable to supervene are infection of the wound 
with a resulting general septic infection, pneumonia from the as- 
piration of blood, and interference with the cardiac function due 
to injury to the pueumogastric nerve. The recurrent laryngeal 
nerve if injured causes hoarseness or loss of speech. 

If the patient is able to swallow, fluids can be given by mouth, 
•or, if unable to swallow, per rectum. The stomach tube may 



212 MINOR SURGERY. 

also be used. The oesophageal wound should be cleansed each 
time the patient swallows food, as there is apt to be some leakage 
from the opening with the possible danger of infection. 

ABSCESS OF THE NECK. 

Suppurative processes in this region are often of glandular 
origin. The affection begins with involvement of one or more 
lymphodes, which are enlarged and tender. The inflammation 
may continue for a week or more, chill and fever follow, and the 
local symptoms are more pronounced. 

If the patient is neglected or improperly treated, and the pus 
is not liberated, the abscess will enlarge, and on bursting its 
limited boundary become a true phlegmon. The tissues are then 
rapidly destroyed and dissected away from each other by the 
burrowing pus. The larger vessels become involved and may be 
even perforated. The tissues become engorged and swollen to 
such an extent that pressure is made upon the trachea and 
cyanosis is the inevitable result. 

Treatment. — In the acute and quick forming variety it may 
be necessary to perform tracheotomy without delay to afford 
relief from the impediment to respiration. In emergencies a pre- 
liminary tracheotomy can be done without general anaesthesia, 
though if there is time chloroform or ether had best be given. 
If there be a localized abscess the incision should be made at the 
most prominent point and in the direction of the natural folds of 
the neck, and so avoid unnecessary scarring. Transverse in- 
cisions are less apt to be followed by cicatricial contraction than 
vertical incisions in the median line. One should dissect carefully 
in these parts as there are so many important structures that 
ought not to be injured. At times it may be necessary to divide 
quite large vessels, but these should always be clamped before 
division. When the knife enters the abscess cavity the fact will 
be announced by the appearance of a drop of pus. The closed 
blades of an artery or dressing forceps should be inserted in the 
opening thus made and withdrawn with sufficient force to enlarge 
the opening. The cavity is then cleansed with peroxide of 
hydrogen, and the parts explored with a clean finger. If there 



FOREIGN BODIES IN THE NOSE. 213 

is necrotic tissue within the cavity the use of the sharp spoon 
curette is indicated. If there is considerable oozing the cavity 
should be packed with dry sterile gauze for a few hours. A 
drainage tube is generally necessary. Moist dressings are desir- 
able. The parts should be daily inspected, and if pus pockets 
reform these must be drained. Dry dressings are indicated when 
the abscess cavity shows a tendency to fill in. For therapeutics, 
see Abscess. 

FOREIGN BODIES IN THE NOSE. 

Children often push foreign bodies into the anterior nares and 
these, on becoming fastened in the nasal chambers, give rise to a 
muco-purulent or bloody discharge, and also partial obstruction 
to breathing. Small stones, shoe buttons, hairpins, slate pencils, 
beads, peas and beans are among the objects more commonly 
used. Adults with nervous ailments have been known to form 
this peculiar habit. Beans and peas absorb the normal moisture 
of the nostril, which causes them to swell and severe pain may 
result. 

When the patient will submit or can be forcibly controlled the 
nasal cavities should be illuminated with the aid of a forehead 
mirror. The irritation caused by the presence of the object may 
cause swelling of the nasal mucous membrane, and so hide the 
foreign body. If this be the case the application of a four per 
cent, cocaine solution will lessen the oedema, and the offending 
body can be detached with a probe. It is, as a rule, impacted be- 
tween the lower or middle turbinate bones and the nasal septum. 
In children it is often a wise plan to give a general anaesthetic so 
the child can be managed, and also to avoid possible injury to the 
mucous membrane. When the body is located its removal by the 
nasal forceps or a small blunt hook is advisable. One should be 
careful not to injure the soft tissues unnecessarily. If foreign 
bodies cannot be removed in this manner they may be flushed out 
of the nostrils with a douche. The tip of the nasal douche tube 
is placed in the nostril opposite to the one which is occluded, the 
patient bending the head forward with the mouth open. The 
stream of water is allowed to flow around the posterior border of 



214 MINOR SURGERY. 

the septum and into the obstructed nostril behind the foreign 
object. The pressure thus formed forces the body out. Some- 
times it is necessary to push the foreign substance back into the 
pharynx and remove it from this location. 

RHINOUTHS. 

Nasal calculi are formed by foreign bodies, hardened pieces of 
mucous, blood clots and small pieces of bone becoming encrusted 
with Carbonate or Phosphate of lime salts from the normal nasal 
secretions. Nose stones give rise to the same symptoms as those 
given under foreign bodies in the nose. As these calculi are a 
long time in forming the condition is more often found in adults. 

The treatment includes the application of a four per cent. Co- 
caine solution, the location of the calculus by the probe, and its re- 
moval by the nasal forceps. If very large the stone may have to 
be crushed with forceps or in very hard cases with a lithotrite. 
For these large stones it is better to give an anaesthetic in order 
that the patient may be better controled. 

EPISTAXIS. 

Nose bleeding is due to traumatism, as from blows, operations 
in the nose, and fractures of the base of the skull; spurs of bone 
on the nasal septum pressing on the opposite side, causing a 
laceration of the mucous membrane; the removal of hardened 
mucous crusts, high altitudes, vicarious menstruation, astringent 
applications to bleeding hemorrhoids, valvular heart disease, 
acute diseases and malignant disease. Very often bleeding from 
the nose is nature's method of relieving an over accumulation of 
blood. 

Treatment. — First ascertain the cause and if found remove 
it. Vicarious epistaxis should not be stopped unless the blood 
loss is alarming and measures should be taken to relieve the ab- 
normal condition. In moderate cases the patient should remain 
in the upright position with the head inclined slightly forward so 
as to prevent the blood from entering the throat. If faintness 
occurs, the patient should lie down upon the side affected. In 
very many instances the hemorrhage comes from the anterior 



EPISTAXIS. 



215 



septal artery which is located in the lower part of the septal 
cartilage, about one-half inch from the nasal opening. Firm 
pressure upon the outside of the nose will tend to control the 
bleeding from this point. It is a good plan to insert a plug of 
gauze or wool over the wounded artery before applying pressure. 
If continued force does not check the bleeding from this source 
the parts will have to be cleansed, a four per cent. Cocaine 
solution applied and the bleeding point touched up with the 




Fig. 49. Plugging the nares for Epistaxis. 

actual cautery or Chromic acid. Pressure upon the whole upper 
lip will aid in the control of the hemorrhage. Simple measures 
to control slight epistaxis consist of blowing into the nostril 
powdered burnt Alum or Tannic acid. Ice water snuffed into 
the nose will relieve simple cases. Fresh lemon juice applied 
locally will help, as will also a spray of Antipyrine, five per 
cent, solution. 

Epistaxis, due to nasal operations, is effectively controlled by 
tampons of Bichloride or plain gauze or oakum. Plain gauze 
soaked in Hydrogen peroxide is of value. The tampon should 
be large enough to cover the wound and the tissues beyond 
and also to make firm pressure on the bleeding surface. This 



2l6 MINOR SURGKRY. 

may be left in place for twenty-four to forty-eight hours, and 
before removing the tampon must be first well softened with a 
mild antiseptic solution. This is of importance because the 
gauze fibres adhere to the raw surface and if pulled away too 
forcibly might excite a recurrence of the bleeding. To prevent 
bleeding in post operative wounds the injection of several minims 
of the following solution has been found quite effective : 

Suprarenal extract I drachm. 

Boric acid . . 16 grains. 

Aqua Cinnimon 4 fluid drachms. 

Aqua Camphora 1 fluid drachm. 

Aqua q. s .... 2 fluid ounces. 

Macerate for four hours and filter. 

When the hemorrhage is from the posterior portion of the nos- 
tril the posterior nares will require plugging. To do this a small 
soft rubber catheter through which is passed a thread or strand 
of catgut about two feet in length and a pledget of gauze are re- 
quired. The instrument is passed through the nostril and when 
the tip and the end of the thread show in the throat the end of 
the thread is grasped with forceps, drawn out of the mouth, and 
fastened about the centre of a small gauze roll. The end of the 
thread at the other end of the catheter is then pulled upon and 
the gauze pledget is drawn firmly into the posterior nares and the 
wings of the tampon press against the bleeding point. The 
catheter is then withdrawn and the two strings are tied firmly 
over the upper lip. It is necessary to hold the soft palate forward 
with the index finger so the tampon can pass behind it. If this 
procedure does not stop the bleeding the anterior string can be 
threaded with a small piece of antiseptic gauze which is pushed 
back with a probe until it comes in contact with the piece first 
introduced. Several pledgets are successively introduced until 
the anterior and posterior nares are thoroughly packed. The 
posterior plug can be removed in twenty-four to forty-eight hours 
by traction on the cord passing through the mouth. The 
anterior plugs can be taken out with nasal forceps. 



RETROPHARYNGEAL ABSCESS. 217 



THERAPEUTICS. 

Aconite. — Epistaxis in excited and angry individuals; bright 
red blood. The characteristic symptoms produced by the drug 
are present. 

Arnica. — Epistaxis is due to traumatism or physical exertion. 

Belladonna. — Epistaxis with throbbing headache. Red face 
and red blood. Bleeding from nose in children at night. 

Bryonia. — Vicarious epistaxis. Bright red blood. Worse 
early in the morning. 

Cactus. — Epistaxis with cardiac disturbances. 

China. — Epistaxis causing considerable loss of blood with re- 
sulting weakness. 

Crocus. — Epistaxis with dark and stringy blood. 

Hamamelis. — Epistaxis with dark blood. Vicarious dis- 
charge. General varicosed condition. 

Pulsatilla. — Epistaxis due to vicarious condition. Blood 
dark and coagulated. 

Phosphorus. — Hemorrhagic diathesis. Long continued epis- 
taxis. 

Sepia. — Epistaxis during pregnancy. 

Melilotus. — Highly recommended when the epistaxis relieves 
periodical headaches. 

RETRO-PHARYNGEAL ABSCESS. 

A retro- pharyngeal abscess may be defined as a collection of 
pus in the connective tissue between the pharynx and the vertebra. 
Infants under one year of age are frequent sufferers. It is more 
often caused by necrosis of the upper vertebra in patients with a 
bad history. Acute pharyngitis, septic infection in scarlet fever 
and abscess of the tonsil are causes. When occurring in adults 
syphilis or erysipelas excite the condition. It causes a bulging 
of the pharyngeal wall either in the median line or toward one 
side. Swallowing and respiration may be interfered with, and 
the voice is high pitched. Fever and chills may follow. The 
condition is to be diagnosed from croup, cerebral and digestive 
disorders, and laryngeal oedema. In children less than one year 



218 MINOR SURGKRY. 

of age when the abscess is in the median line it can be opened in- 
ternally. A short longitudinal incision is made which is enlarged 
by introducing closed forceps into the abscess and withdrawing it 
with the blades opened. The internal incision is apt to be fol- 
lowed by septic broncho-pneumonia from the aspiration of pus, 
therefore it is best in nearly all cases to evacuate these abscesses 
from the outside of the neck. Chloroform is the best agent for 
producing anaesthesia in these cases. Swelling is often visible 
externally. 

The patient should be placed with the head toward the least 
affected side. Everything in connection with the operation 
should be well sterilized. Chiene's incision is made from the 
mastoid process down alongside the posterior border of the sterno- 
cleido-mastoid muscle, and then to go bluntly down with the finger 
and probe to the anterior aspect of the vertebral bodies. By 
dividing the deep fascia and retracting anteriorly the muscle with 
the complexity of vessels, the retro-pharyngeal space is quickly 
reached. An aspirating needle can be used to locate the pus cav- 
ity, and when found a pair of dressing forceps can be introduced 
closed alongside the needle and withdrawn open. The cavity 
should be cleansed with Thiersch's solution, and a drainage tube 
introduced. The part is irrigated daily, and the tube shortened 
as healing progresses. When the abscess is evacuated the un- 
pleasant symptoms rapidly disappear. Should the constitutional 
symptoms remain one should be suspicious of other foci of infec- 
tion which must be sought for and properly treated. 

ADENOID GROWTHS. 

Adenoid vegetations are not tumors in the sense usually im- 
plied by this term. Normally, there exists between the orifices 
of the Eustachian tubes an adenoid tissue analogous in structure 
to the lymphoid constituents of the tonsil, and often designated 
" third tonsil," " Euschka's tonsil," and " pharyngeal tonsil." 
This tissue hypertrophies rapidly, owing to its rich vascular sup- 
ply, and soon fills the vault of the pharynx and encroaches on the 
orifices of the Eustachian tubes. The direct result is the establish- 
ment of mouth-breathing and, what is more important, the loss 
of hearing. 



ADENOID GROWTHS. 219 

Bosworth says, "Probably a very large majority of cases of 
ear trouble in children under twelve years are dependent upon 
vegetations in the pharyngeal vault. ' ' 

When the condition does exist it is surprising to find the train 
of symptoms resulting. The establishment of mouth-breathing 
is the symptom which first attracts attention. It is not so 
noticeable by day, although the child may present the vacant ex- 
pression characteristic of this condition. At night the sleep is 
disturbed, the respirations are loud and snorting, with deep, 
noisy inspirations. When the mouth-breathing has persisted for 
a long time definite changes are brought about in the face, 
mouth and chest. The face is so peculiar and distinctive that 
the trouble may be evident at a glance. The expression is dull, 
heavy and apathetic, due in part to the fact that the mouth is 
habitually left open. 

In long-standing cases the child is very stupid looking, re- 
sponds slowly to questions, and may be sullen and cross. The 
lips are thick, the nasal orifices small and pinched-in looking, 
and in the mouth the superior dental arch is narrowed and the 
roof considerably raised. 

Other important symptoms include post nasal catarrh, head- 
ache, general listlessness, and an indisposition for mental or phy- 
sical exertion. Habit-spasm of the face is occasionally seen. 
Mouth-breathers are usually dull, stupid, and backward, which 
is due largely to the loss of hearing. Alterations in the chest oc- 
cur in cases of long standing, forming what is commonly called 
" pigeon breast." 

In the diagnosis of adenoid vegetations, digital examination is 
superior to rhinoscopy. The index finger explores the vault of 
the pharynx, which in slight cases is felt to be occupied by 
unusually soft mucous membrane, bleeding readily and having 
altogether a sensation of undue thickness and friability. In 
marked examples there is the same yielding, almost gelatinous 
feeling, while the blocking of the cavity is more perceptible. In 
typical cases the finger, however gentle the examination may 
have been conducted, is, on withdrawal, tinged with blood. The 
sensation imparted to the finger has been described as that of a 
' ' bunch of worms. ' ' 



220 MINOR SURGERY. 

Treatment. — The growths are easily removed with special 
forceps or curette. Some physicians use their finger-nail. To 
secure the ideal conditions for an operation for the removal of 
these growths general anaesthesia is necessary, as local anaesthesia 
has many disadvantages. 

When anaesthesia is employed a mouth gag is required. A 
tongue depressor turned on edge and held between the teeth acts 
admirably. When enlarged faucial tonsils exist, and they gen- 
erally do in this class of patients, it is wise to remove them first, 
as the hemorrhage of the pharyngeal vault obscures the field of 
operation if the adenoid growth is first removed. An assistant 
then draws the head, shoulders and greater part of the trunk off 
from the table so as to allow the blood to escape from the nostrils. 
The curette should be passed forward to the septum before any 
pressure is made, and then pushed against the vault of the 
pharynx and drawn backwards, care being taken to avoid the 
Eustachian tubes, for fear of causing an attack of acute otitis 
media. A few quick sweeps in an anterio-posterior direction is 
all that is necessary. When there is a great quantity of tissue 
we sometimes remove the main mass by means of forceps, and 
then finish with the curette. A digital examination of the 
pharynx should then be made to discover if the curettage has 
been complete. The patient is supported by the assistant in the 
same position for a few seconds until the hemorrhage shows an 
inclination to abate. Whenever coughing or crying begins the 
head and shoulders may be raised, after which bleeding usually 
ceases. We have never met with sufficient bleeding to justify 
alarm or require special treatment; but the few recorded cases of 
dangerous and even fatal hemorrhage, while forming no contra- 
indications, excepting in cases of hemophalic subjects, should 
make the operator instruct those with the patient to be on the 
watch. 

After Care. — When the bleeding stops the patient is put in 
bed between hot blankets, with hot water bottles placed at the 
feet. The operation is often followed by headache, and a certain 
amount of sore throat exists for a day or two, while occasionally 
middle ear catarrh results. The sore throat is much less marked, 
however, if the patient be instructed to suck pieces of ice immedi- 



FOREIGN BODIES IN THE OESOPHAGUS. 221 

ately after the operation. For some days afterward it is desirable 
to avoid exposure to cold, and, above all, to septic or contagious in- 
fluences. It is advisable to give a liquid diet for a few days. 

Local Anaesthesia. — There is a class of cases in which an 
anaesthetic is contra-indicated, and others will not take one. For 
these patients we use an eight per cent, solution of Eucaine applied 
with a brush. It is difficult, however, to procure satisfactory 
local anaesthesia by it, the explanation probably being that the 
drug never reaches the actual point at which the tissues are sev- 
ered. Patients of this class may sit or stand before the operator. 
An assistant holds the head and hands, and after the tongue is 
depressed the curette is introduced and used as described above. 

FOREIGN BODIES IN THE CESOPHAGUS. 

If a foreign body has lodged in the oesophagus there is not 
as a rule complete occlusion. It is usually impossible to 
swallow, though some liquid nourishment can be taken. There 
is little or no tendency to cough, no matter how much the breath- 
ing may be interfered with. Inflammation with or without the 
formation of pus may cause so much swelling that the obstruc- 
tion becomes complete. If a foreign object be within reach of 
two fingers it is easily removed. If not, a pair of curved forceps 
devised for work in the oesophagus should be used. In an emer- 
gency a hairpin can be straightened out and one end bent round so 
as to make a loop, and this used to try and dislodge the body. 
Some one has found that blowing forcibly into the ear tends to 
excite reflex action, during which the foreign body will be ex- 
pelled. The introduction of the elastic oesophageal bougie will 
demonstrate the location and presence of any foreign substance. 
This instrument before it is passed is lubricated with vaseline, 
butter, white of an egg or glycerine. The patient is instructed 
to throw the head back so as to bring the axis of the mouth and 
pharynx in line with that of the oesophagus. The bougie is 
passed so that the point will glide over the base of the tongue 
and touch the posterior wall of the pharynx behind the larynx. 
Gentle force is used to urge the instrument downward into the 
oesophagus, though it must be kept in the median line. Spasm 



222 



MINOR SURGERY. 



of the glottis prevents the instrument passing into the larynx. 
If the sound touches the occluding substance this is easily noted 
by its stoppage. If the calibre of the tube is not completely 
occluded the production of emesis will dislodge the body. Giv- 
ing the patient milk to swallow and waiting a few minutes for it 
to curdle in the stomach and then forcing the patient, to vomit is 
often effective. The hypodermic injection of -^ gr. of Apo- 
morphia is a quick acting emetic. Irritation of the fauces with 
the finger is a simple method to excite vomiting. 




Fig. 50. Esophageal instruments. 

The umbrella probang is a useful instrument to dislodge sub- 
stances that do not completely close the canal. The probang is 
introduced after being lubricated, closed and is passed down until 
the bristles are well beyond the point of occlusion. Pressure 
upon the handle causes the bristles to project and completely fill 
the caliber of the tube. The probang is then withdrawn and 
with it the foreign body. 

Should there be complete occlusion, efforts to produce emesis 
should not be made nor should one introduce a bougie to push 



FOREIGN BODIES IN THE LARYNX AND TRACHEA. 223 

the object into the stomach. Where there is complete occlusion 
and there arises pressure upon the trachea the oesophagus must 
be opened by an external incision. Inversion of the patient to- 
gether with sharp blows upon the back are sometimes successful 
in getting rid of the object. 

When peculiar objects like coins, marbles, slate-pencils or 
pins, are taken into the stomach it is a mistake to give a purga- 
tive. The best plan is to give plenty of rather coarse food, 
especially vegetables, so that the foreign body may be surrounded 
with the waste and carried out of the body without injuring the 
walls of the intestines. Occasionally the stomach has to be 
opened and the offending object removed. 

FOREIGN BODIES IN THE LARYNX AND TRACHEA. 

A varied assortment of foreign objects gain an entrance into 
the respiratory tract by passing through the mouth and entering 
the air passages during natural or spasmodic respiratory effort. 
Not infrequently foreign bodies are introduced by gun-shot 
wounds and also by objects that are held in the mouth when the 
patient goes to sleep. When a foreign body enters the larynx it 
causes symptoms of distress immediately. Pain, continued cough, 
dyspnoea and temporary indications of asphyxia are noted. 
Hemorrhage may result from irritation by sharp pointed objects. 
If the object descends into the lungs, pneumonia will develop. A 
foreign body may become lodged just back of the epiglottis, lay 
across the glottis, in the ventricle, between the vocal cords, or it may 
drop into the trachea or bronchi. A body lodged in the ventricles 
will not excite irritation so much as one situated in the opening 
of the glottis. Large particles of food and irregular objects, as a 
rule, become fixed in the opening in the glottis; flat buttons or 
coins generally become fixed in the ventricles of the larynx. 
Sharp pointed bodies more often lodge in the epiglottis, the ary- 
glottic fold or else in the supra-glottic portion of the larynx. 
Small round objects more often drop into the trachea or bronchi. 

If foreign bodies are not removed they become fixed or mov- 
able. Generally, the irritation due to their presence causes 
swelling of the mucous membrane which anchors the body in one 



224 MINOR SURGKRY. 

position. The ascending and descending columns of air passing 
through the trachea tend to change the position of foreign bodies 
in this part. Violent respiratory movements change the position 
in the larynx. Cases are on record where a movable body in the 
larynx became lodged in the opening of the glottis causing ob- 
struction and asphyxia. Sharp-pointed and angular bodies often 
penetrate the mucous surfaces which swell about them. An ab- 
scess may be the result and cause death. 

The situation of the irritant is of much importance and may be 
determined by palpation with the finger and examination with 
the laryngoscopic mirror. The latter should be tried in every 
case old enough to be managed where the muscular spasm will 
not prevent. A four per cent, solution of Cocaine sprayed into 
the pharynx will aid. Auscultation will sometimes determine 
the location of a body in the lower respiratory tract. 

Treatment. Children not infrequently are relieved by hold- 
ing the body up by the legs with the head hanging down. A 
moderate blow upon the back with the open hand or a quick 
strong squeeze of the chest should be given when the body is in- 
verted. This treatment favors displacement, especially in small 
round bodies, and there is no reason why the same method should 
not be applied to adults when practicable. 

If there is danger of immediate asphyxia artificial respira- 
tion by Sylvester's method must be begun and continued until 
measures are taken for permanent relief. It may then be neces- 
sary to perform tracheotomy. If the patient is turned on his face 
or shaken violently the object may be dislodged and expelled. 
If the object is lodged in the larynx attempts may be made to 
remove it by special forceps and hooks. If it is necessary to 
open the trachea a foreign body lodged in the trachea, bronchi 
and also sub-glottic bodies can be removed through the tracheal 
opening. When the foreign body has passed into the trachea 
or bronchi, the necessity for operative interference will depend 
upon its size, location and shape. If it is small and does not 
disturb the respiratory function markedly, and is lodged rather 
deep, it is not necessary to remove it, because it is not apt to 
cause serious trouble. There is the uncertainty of finding a 
small object and there is, too, a certain risk run when the trachea 
is opened and instruments are used in the respiratory tract. 



CHAPTER XVII. 



THE EXTREMITIES. 
WOUNDS OF -MUSCLES AND TENDONS. 

Wounds that cause a complete division of a tendon or tendons 
are followed by retraction of the divided ends and loss of func- 
tion. The treatment requires that the hemorrhage be checked 
and the parts cleansed as well as the surroundings will permit. 
Then the flexor and extensor tendons of the hand, wrist and each 
finger should be carefully tested. If there is limitation of 
motion to a considerable degree or total absence of motion there 
has probably been a division of tendons or nerves. Transverse 
wounds are more liable to do serious injury to these structures 
than longitudinal ones. If the patient be a sensitive individual 
or a child, a general anaesthetic will be required, though ordinarily 




U 



Fig. 51. Method of suturing the annular ligament of the wrist. 

local anaesthesia will be all that is necessary for tendon suture. 
The solution should be injected into the surrounding tissues but 
not into the tendon or its sheath, for these, when inflamed, are 
not sensitive. The wound edges are retracted and blood clots 
turned out. The distal end of the divided tendon retracts but 
little while the proximal ends do retract and are pulled up by 
their muscles. Massage and motion of the crippled member will 
usually bring the distal portion of the tendon into view. Quite 
forcible massage may be required to bring the proximal portion 
15 



226 



MINOR SURGKRY. 



into sight. It is occasionally necessary to incise the overlying 
tissues and search for the proximal end, though this is rarely 
done in recent cases. The ends of the tendon should be smoothed 
and shreds trimmed away. The suture material should be of 
strong silk and introduced longitudinally into the overlapped 
ends. If the tendon is wide and there is considerable space to 
fill in between the separated ends this can be done by splicing. 

L 



1 

Fig. 52. Anderson's method of tendon-lengthening. 

A horizontal incision is made half through the tendon, an inch 
or more from the lower extremity, and a longitudinal cut to 
within a quarter of an inch of the divided end. These incisions 
release a portion of the tendon that may be turned and united 
with a flap taken in the same way from the other side of the torn 
structure. Where many tendons have been cut, care should be 
taken to find out the ends which belong together. The apparent 
relations which the ends hold to each other as well as anatomical 




Fig. 53. Tendon sutures. 
i,ofL,eFort 2, of L,e Dentu. 3, of Lejars. 



knowledge should be taken into consideration. A muscle or a 
tendon can be attached to an adjacent structure when it is really 
impossible to find the two ends of the divided part. This pro- 



WOUNDS OF THE MUSCLES AND TENDONS. 227 

cedure will tend to prevent total paralysis of the finger or limb to 
which the tendon is inserted. If fibers of the torn muscles pro- 
trude through the skin wound these should not be snipped off, but 
should be pushed back, even if the opening has to be enlarged. 

After the sutures in the tendons and skin have been tied the 
parts are dressed with sterile gauze and bandaged. The finger or 
limb should then be either flexed or extended and kept for several 
weeks in the position which relaxes the muscles by crinoline or 
plaster of Paris bandages and splints. As a general rule, ten- 
dons divided subcutaneously by a clean knife as in the closed 
operation for club foot reunite satisfactorily as to function, 
though where there is an open wound and the adjacent structures 
are freely divided sutures are always necessary for good union of 
the cut tendon. The silk suture used in uniting tendons need 
not be removed unless suppuration, due to its presence, develops. 



^T\ 



Fig. 54. Czerny's method of tendon-lengthening. 

Athletes and laborers often experience a subcutaneous rupture 
of a few muscular fibres. The symptoms come on after a sudden 
strain or wrench and consist of a sudden, sharp and local pain, 
followed later by ecchymosis. The treatment consists of hot air 
baths, strapping with adhesive plaster, massage and rest. 

A complete rupture of a muscle or its accompanying tendon 
has been known to occur. Extreme violence and sudden mus- 
cular contraction are the cause of this unusual condition. Dis- 
eased muscles may rupture even under a slight degree of force. 
The tendons of the gastronemius, plantaris and soleus muscles of 
the calf of the leg, and the long head of the biceps are most fre- 
quently lacerated. The symptoms of this condition are sudden, 
sharp pain, a possible distinctly heard snap, loss of function, a 
depression of the surface, and ecchymosis. The treatment of 
torn muscles and tendons requires ample incisions over the parts 
and the introduction of silk or chromicized catgut sutures. The 
limb should then be immobilized so that there will be as little 
tension as possible on the sutured ends. Plaster of Paris and 



228 MINOR SURGERY. 

crinoline bandages, splints, adhesive plaster straps are conducive 
to this end. 

Arnica, Calendula and Hypericum are indicated. 

DISLOCATION OF MUSCLES AND TENDONS. 

A tendon may become dislocated, due to sudden force applied 
at a point where it turns about at a bony elevation. The pos- 
terior tibial tendon, the peroneal tendons and the long head of the 
biceps are more frequently drawn out of place than any others. 
The treatment consists of reduction of the luxation, which is 
usually accomplished by a combined relaxation of the muscle and 
pressure upon the affected tendon. It may be somewhat difficult 
to keep the tendon in its normal place after reduction, as the ten- 
don sheath is torn and allows a freedom of movement that inter- 
feres with healing. Pressure with gauze pads and an elastic 
bandage are sometimes effective to keep the parts in the normal 
relations, though recurrence of the dislocation is very apt to re- 
sult from sudden violence. It may be necessary to incise the 
skin and suture the disturbed parts before a cure can be effected. 
Massage should be instituted early and also slight passive motion. 
The muscles have been known to leave their normal positions and 
under such conditions a luxation really occurs. This class of 
cases require treatment by suturing to the adjacent muscles and 
fascias. Manipulation and continued pressure with pads of 
gauze and the elastic bandage are sometimes effective. Arnica,. 
Bryonia, Rhus tox., Calendula and Hypericum are indicated. 

TENO-SYNOVITIS. 

Inflammation of the sheath of a tendon is known as teno- 
synovitis. Wounds, over-use, rheumatism, gonorrhoea and 
syphilis are the general causes. The symptoms of acute teno- 
synovitis include severe pain and local constitutional symptoms 
of inflammation that may be followed by pus formation and 
necrosis of the phalanges. If not relieved the hand and arm be- 
come involved by pus burrowing along the tendon sheaths and 
a phlegmonous cellulitis intervenes. 



TENO-SYNOVITIS. 



229 



Treatment. — Ice bags are indicated early, also elevation and 
support of the affected member. Hot applications and the hot 
air bath are of great value. If pus has already formed a longi- 
tudinal incision is made in the middle line of the tendon dividing 
all structures down to the bone. This will prevent burrowing of 
pus along the sheaths and the spread of the infection. Incisions 
must be made early and in some instances even before suppura- 
tion occurs if the surgeon realizes the inflammation is sure to re- 
sult in pus formation. The wound should be irrigated with Bi- 
chloride of mercury solution, 1 to 2,000, or Hydrogen peroxide, 
packed with moist gauze dressings, elevated and supported by 




Fig. 55. 



1, 2 and 3, Incisions for felon of finger and for ordinary suppuration. 4, Palmar 
abscess. 



splints. Should necrosis develop,. resection of the diseased bone 
is required, or it may be even necessary to amputate a portion of 
a finger or limb. Impairment of the joint function often results 
even in well treated cases of acute teno-synovitis. Chronic in- 
flammation of the tendon sheaths is occasionally characterized by 
peculiar crackling sounds produced by motion. The sounds are 
very similar to crepitation noticed in fractures. The crepitus 
usually occurs in the forearm and is probably due to enlargement 
of the tendon sheaths by lymph, which causes a scraping sensa- 
tion when the tendons glide in their coverings. Pain, tenderness 



230 MINOR SURGERY. 

and swelling constitute the symptoms which are excited by 
rheumatism and excessive muscular action. The treatment is 
rest, the hot air bath, massage, hot water irrigations and the 
elastic bandage. Arnica, Bryonia, Rhus tox. and Hypericum 
are most* often indicated. 

WOUNDS OF JOINTS. 

In addition to sprains, penetrating wounds of joints are of fre- 
quent occurrence. Such a wound may be serious because of the 
possibility of causing infection of the joint. Subcutaneous in- 
juries of joints occurring in connection with fractures and dis- 
locations are not of great importance unless the presence of 
certain specific germs sets up an irritation. If the joint cavity 
has been opened by a wound in the adjacent structures, the 
escape of synovial fluid will announce the fact. The albuminous 
fluid of a ruptured bursa near a joint may be misleading. 
Synovitis and arthritis are often the result of mismanaged 
joint wounds. 

Treatment. — Perfect rest to the injured part and the applica- 
tion of cold will in many instances prevent further trouble. We 
have seen the complicated knee joint penetrated by dirty ob- 
jects and subsequent inflammation aborted by rest of the part and 
the use of ice bags. The wound must be first well irrigated with 
Bichloride of mercury solution, 1 to 3,000, and provision made for 
drainage. If the wound is one of small calibre it may be difficult 
to drain. The patient is then put to bed, the joint given com- 
plete rest, aided by splints, sand bags and bandages. It is well 
to elevate the extremities. The wound having been dressed 
with gauze, ice bags are applied with the expectation of prevent- 
ing further trouble. The first symptoms of active inflammation 
require immediate opening of the joint and thorough irrigation 
with a mild antiseptic solution. A saturated solution of Boracic 
acid, Thiersch's solution or Mercuric bichloride, 1 to 4,000 solu- 
tions, are good agents. If the wound is rather more than a 
puncture the joint should be thoroughly irrigated when first seen 
and drainage tubes inserted. If there is no doubt but that the 
wound is septic from the beginning, free incision, irrigation and 



INJURIES OF NERVES. 



231 



drainage are required. If pus forms, a good method is to open 
the joint and irrigate the cavity with the Bichloride solution and 
follow with a few ounces of pure Carbolic acid in solution. This 
is allowed to remain for one minute and the joint is then flushed 
out with alcohol, which neutralizes the corrosive effect of the 
acid. Glass drainage tubes are inserted and the parts given rest. 




Esmarch siphon. 



Under this treatment the largest joints can be successfully opened 
and drained with every prospect of a perfect result. The same 
method is highly recommended in the treatment of tuberculous 
abscesses of joints. Aconite, Arnica, Calendula, China, Mer- 
curius, Hepar sulph. and Silicea are indicated. 



INJURIES OF NERVES. 

Nerves are subjected to the various kinds of wounds, being 
more often lacerated, incised, punctured and contused. The lat- 



232 MINOR SURGERY. 

ter class is not infrequently noted in fractures about the wrist 
joint when the ulnar nerve is compressed. A lacerated wound of 
a nerve may completely divide it or only a portion of the nerve 
tissue may be lost. Dislocation of the ulnar nerve from its nor- 
mal location behind the internal condyle of the humerus is not 
uncommon. 

The symptoms of nerve injuries vary from slight pain to 
paralysis. In a slight wound there is pain at the point of injury, 
with a tingling or even numb sensation along the nerve filaments. 



r^c 




Fig. 57. Suture of a nerve by splitting the ends. 

A foreign object in contact with a nerve gives rise to spasms of 
the muscles. Neuritis and neuralgia may occur later. If the re- 
sulting cicatrix involves the nerve its function is impaired or 
even lost. As a result there is a disturbance of nutrition which 
occasions atrophied and contracted muscles, oedema of the skin, 
lowered local temperature, loss of hair and sensation to contact. 
Partial or total loss of function also occurs. 

Treatment. — Nerve injuries that result in complete division 
require immediate suture. The wound may be enlarged if neces- 
sary, and when the divided ends are exposed catgut sutures are 
placed in such a manner that the parts will be thoroughly ap- 
proximated. If part of the nerve tissue has been excised, the 
gap may be filled in by either stretching both ends and suturing 



& 
q 



Fig. 58. Nerve suture. 



or by splicing. The latter method consists of cutting flaps from 
both sides, turned so as to be in apposition and catgut sutures are 
introduced. The splicing is done in much the same manner as is 
described for ruptured tendons. Primary nerve suture is fol- 



WEBBED FINGERS. 233 

lowed in the course of several weeks or months by nearly com- 
plete return of function. To aid in this it is well to begin treat- 
ment by massage in ten days or as soon as the wound is healed. 
It is often a good plan to begin gentle rubbing and kneading of 
the paralyzed muscles even earlier, so long as the wound is not 
interfered with. Galvanic electricity should be employed. When 
a large nerve has been divided and there is a total loss of function 
of the part which is supplied by the injured nerve, it is really 
necessary to expose the nerve trunk, excise the scar tissue and 
apply catgut sutures as in primary suturing. This treatment is 
indicated even after months have elapsed since the injury was re- 
ceived. The operation, if properly carried out, is followed by ex- 
cellent results. Of course, rigid asepsis should be observed. 
Hypericum is the best remedy for injured nerve tissue. Rhus 
tox., Aconite and Arnica will be indicated also. 

WEBBED FINGERS. 

This is a congenital affection in which there is a more or less 
perfect fusion of one or more of the fingers. The skin alone may 
be affected or even the bones may be adherent. The function of 
the hand is not seriously impaired. Occasionally there is an 
extra digit in conjunction with the other deformity, which has 
been termed syndactylism. 

Treatment. — When the bones of any two digits are united 
throughout their length it is not good surgery to separate them. 
The best method of treatment is the flap operation. A flap is 
dissected from the palmar surface of the first finger, and a second 
flap is taken from the dorsal surface of the next, by incisions 
made along the median line of the fingers. The two flaps are 
dissected away so that the palmar flap of the second finger re- 
mains attached to the first finger, while the dorsal flap from the 
first finger remains attached to the second finger. The flaps are 
then brought around, the raw surfaces accurately approximated 
and their edges held in apposition by the introduction of sutures. 
The fingers should be well separated when dressed because of a 
possible bad result. When the bones are only united for a short 
distance they may be cut or sawed apart. Examination with the 
X-rays aid in the diagnosis. 



234 



MINOR SURGERY. 



Webbed toes are not as often noted as webbed fingers. This 
condition does not inconvenience the individual, though should 




Fig. 59. Diday's operation for webbed fingers. 

an operation be desired it can be carried out as described for 
webbed fingers. 

WARTS. 



A wart may be defined as an enlargement of the cutaneous 
papillae. Hard warts are very frequently found upon the hands 
and the soft variety are found at muco-cutaneous surfaces where 
the moisture causes irritation. An intermediate variety is seen 
on the back and neck. Warts, when irritated, bleed profusely, 
and the larger ones may have a fetid odor, due to the decomposi- 
tion of the secretions. This type is commonly found in the 
rectum or about the genitals. 

Treatment. The hard warts often disappear without treat- 
ment and this has probably given rise to the efficacy of the 
numerous absurd applications. This variety is well treated by 
soaking the part in water as hot as can be borne, three times a 
day, and the application of tincture of Thuja. This easily 
applied method has cured cases of long standing where the 
stronger chemicals have failed to relieve. Thuja is also given 
internally. A drop or two of fuming Nitric acid, Chromic acid 
or Glacial Acetic acid, placed on the part repeatedly, will often 
effect a cure. Excision with scissors is also practiced. Warts 
of the soft variety, when large, require excision and measures 
must be taken to control the hemorrhage arising from the 
operation Pressure with gauze pads, the cautery or powdered 
Tannic acid are effective. If the growth has a pedicle it can be 
ligated and snipped off with scissors. The applications given for 



SABACEOUS CYSTS. 235 

the treatment of horny warts are also useful in the smaller soft 
variety. Electric needles are of special value in the treatment 
of these little tumors. Antimonium crud. relieves flat, hard or 
brittle warts. Causticum is indicated for the fleshy or seedy 
variety. Dulcamara and Calcarea are also useful. 

SEBACEOUS CYSTS. 

This is a collection of "sebaceous substance within a limiting 
membrane. These cysts occur singly or there may be a number 
of them. They ma}^ appear on any part of the body, though the 
scalp and face are more often the sites of these little growths, 
which vary in size; some being as large as an egg and are partly 
buried in the skin. The overlying skin may be normal or it may 
be thickened and reddened, with dilated capillaries. The con- 
sistency of the cyst is due to the thickness of the cyst wall. 
Sometimes sebaceous cysts become inflamed and suppurate. This 
often results in a cure by destruction of the cyst wall. 

Treatment. — Sebaceous cysts can be cured by the removal of 
the cysts with the entire cyst wall. If a portion of the wall is 
left behind, the cyst is apt to recur. Excision by the knife is 
easily done under aseptic measures. A local anaesthetic is all that 
is required to control the slight pain. The sac is dissected out 
carefully without being ruptured until it is completely removed. 
A stitch or two is introduced and a firm dressing and bandage ap- 
plied. If the wound suppurates it should be cleaned daily until 
healed. 

BURSITIS. 

The synovial and mucous bursae become enlarged, the result of 
inflammation, due to traumatism or is indiopathic in origin.* 

Bursitis is the term given to this condition which is more com- 
mon in the chronic form. Some one hundred and fifty bursae 
are found in the body, the majority being located in the ex- 
tremities. Perhaps the most important, from a surgical stand- 
point, are those over the olecranon process, the patella, the 
great trocanter of the femur, and the tuberosity of the ischium. 



236 



MINOR SURGKRY. 



" Housemaid's knee and coal miner's elbow'' are popular terms 
applied to enlarged bursse over the patella and olecranon process. 
Inflammation of the bursal sac may be due to traumatism, gout, 
syphilis and rheumatism. Aneurism may be simulated in some 
bursse where there is a transmitted arterial impulse. 

The presence of acute Bursitis is denoted by the inflammatory 
condition of the bursse, which become enlarged by an increased 
effusion of fluid. The sac when well distended with serum be- 
comes a fluctuating tumor. There is oedema of the surrounding 
tissues and there may be slight crepitus. 




Fig. 60. Housemaid's knee. 



Constitutional symptoms of pus formation demand that the sac 
be opened without undue delay and the contents liberated. If 
the incision is not made early the pus may break through the sac 
wall and burrow under the adjacent structures and become a 
phlegmon. In cases that have been improperly treated pus 
will soon break through the surface, thus forming a fistula. 
If the pus enters a joint, acute arthritis will quickly result. 



BURSITIS. 237 

In chronic bursitis there is little pain and a sensation that the 
limb is weakened and not to be depended upon. The sac is more 
distended with serum and a smooth-surfaced, fluctuating tumor 
will develop. The contents of the sac consist of several ounces 
of dark serum and often, small rice-like bodies. Chronic en- 
larged bursse may become converted into a tumor, fibrous in 
nature by the infl animator discharges and lymph deposits. 

Bursitis is to be diagnosed from synovitis and arthritis of the 
adjacent joint. In the former the swelling is localized, there is 
less interference with the normal motion and the limb does not 
have the tendency to become flexed, so often noted in joint in- 
flammation. 

There is less pain and few constitutional symptoms. If the knee 
joint is affected, one should remember that the effusion of syno- 
vitis and arthritis cause the so-called " floating patella," whereas 
in bursitis the bone is not raised from the surface of the condyles 
of the femur. 

Treatment. — In acute bursitis the limb should be put at rest 
and elevated; compresses of gauze wrung out in lead water, a 
teaspoonful to a pint of water, is a cooling application and will 
lessen the degree of inflammation. Ice bags are of much service 
in the beginning. Aspiration, tapping and injection and incision 
are the operative measures applied to this affection. Aspiration is 
simple to perform, but is inefficient. The use of a trocar and 
the injection of an Iodoform emulsion, or a few drops of Carbolic 
acid, is often successful. Free, early incisions and packing the 
wound with gauze after scraping the cavity with a curette is the 
most effective plan of cure. 

The incision may be made at one or both sides of the swelling 
at the most dependent part. The incision may also be made at 
the most prominent surface of the tumor; the contents removed 
and the sac can be dissected out. If this plan is followed the 
divided wound borders can be closely approximated and primary 
union will follow. If the sac is not removed the wound is packed 
with Bichloride gauze and heals by granulation from the bottom. 
When the sac is dissected out the procedure must be carefully 
carried out or the joint cavity may be invaded. The fibrous- 
like bursal tumors must be dissected out. 



238 MINOR SURGERY. 

Arnica is useful when the swelling and pain result from a blow 
or constant friction of the part. 

Hypericum. Severe pain as if the tissues were being torn 
apart. 

Graphites. Chronic enlarged bursse, with redness and itching. 

Ruta. Dull, heavy pain which feels as if the tissues were being 
squeezed by a heavy weight. 

Hepar, Mercury and Silicea, when there is a tendency to pus 
formation. 

Veratrum viride locally and -internally is sometimes effective 
for the inflammation. 

THECTITIS OR GANGLION. 

Cystic tumors connected with the sheaths of tendons about the 
wrist and ankle joints have been termed "ganglion." The 
cysts are undoubtedly due to traumatism and especially to strains. 

The most simple form of thecal cyst occurs on the back of the 
wrist and has the appearance of a somewhat movable globular 
swelling that is tense and elastic without symptoms of acute in- 
flammation. There is a sensation of weakness of the joint, 
though there is no pain unless the tumor causes pressure on the 
nerve fibres. 

Another variety of the ganglion is often observed in connection 
with the flexor tendons and may involve one or several tendons 
as there is a general dilatation of the sheath cavity. It is called a 
compound ganglion. This variety of cyst is irregular in shape, 
tense and fluctuating and often contains the rice or meUon seed 
concretions of fibrin which cause the sensation of crepitation to be 
imparted to the fingers upon examination. 

The growth is not painful as a rule, but may cause a distortion 
of the fingers and a partial loss of motion when located in the 
palm of the hand. 

Both the simple and compound forms of these tumors are also 
found in the foot, knee and elbow joints. 

Treatment. — Simple cysts are generally treated by rupturing 
the sac by a sharp blow given with a book or any object with a 
broad surface. A single blow is, as a rule, sufficient to cause 



THECTITIS OR GANGLION. 239 

subcutaneous rupture and the contained fluid becomes distributed 
through the cellular tissue and is absorbed. As this mode of 
treatment may not succeed, another method is to pass a small 
sharp-pointed knife through the skin and puncture the sac in 
different directions. The fluid is pressed out of the sac into the 
tissues and as the sac is freely divided the tumor does not readily 
reform. Should these measures fail the cyst may be incised and 
the sac swabbed out with Carbolic acid, 95 per cent., or the 
tumor may be excised. ^ 

Tapping and the injection of curative agents are generally of 
no service, for the fluid reaccumulates. Some success has been ob- 
tained from the introduction into the sac of a ten per cent. Iodo- 
form emulsion. 

The compound ganglion being often of tubercular origin and 
because of their communication with the general synovial cavity 
of the sheath are not so easily cured. These cases require free 
incision into the tumor at its most commanding point in more 
than one place, the evacuation of the small seed-like bodies and a 
thorough scraping of the sheaths of the tendons with a small 
curette. Strict, antiseptic rules must be observed and absolute 
rest of the part will tend to prevent inflammatory results. 

In both forms of Ganglion where excision of the sac is 
practiced, a sufficient amount of the membrane should be left to 
permit of closing the cavity in the joint or sheath by the sewing 
together of the borders with fine catgut. Probably this method 
is the best curative procedure, especially if tubercular infection 
be present. 

Esmark's elastic constriction bandage should be applied to the 
hand and forearm to control the blood supply. All unhealthy 
tissue should be carefully dissected away if necessary, going 
through the annular ligaments, and if a portion of the tendon 
has been excised it may be repaired. The parts should be 
dressed antiseptically and bandaged firmly, being supported by a 
a splint. At the end of forty-eight hours the patient is directed 
to move his fingers lightly and quickly as if playing the piano- 
forte. The first dressing may be left undisturbed for a week. 
Relapses are frequent. 

Phytolacca, Mezereum, Aurum, Causticum and Silicea are 
remedies of efficiency in the cure. 



240 MINOR SURGERY. 



PARONYCHIA OR FELON. 



A felon may be termed a phlegmon of the finger. Acute sup- 
puration of the pulp of the finger may be caused by a tiny 
puncture or it may begin in the bone marrow of the terminal 
phalanx. At first it never invades the tendon sheaths, though if 
neglected they become involved in the suppurative process. 

The symptoms of the affection are extreme throbbing pain, 
swelling, induration of the part, heat and redness. The pain is 
nearly always worse at night. If improperly treated by poulticing 
or if neglected, the pus eventually breaks through the tissues after 
having destroyed more or less of the soft and bony structures. 

Treatment. — Poultices, the common household remedy for 
this condition, should never be used. Early incision is the most 
rational treatment. 

A rubber constriction band should be employed so that blood 
will not obscure the field. 

In adults even local anaesthesia is not always demanded, though 
a few drops of a two per cent. Cocaine solution can be injected 
just above the proposed incision. Chloride of ethyl spray is also 
of value. 

In children general anaesthesia to a slight degree may be neces- 
sary. 

The incision should be made deep enough to liberate the pus, 
though not necessarily down to the bone. The knife should not 
enter the tissues in the median line as is so frequently wrongly 
done, but more towards the lateral surface of the digit in order 
that the resulting cicatrix will not interfere with the sense of 
touch. The pus cavity should be well cleansed with Hydrogen 
peroxide, and then may be dressed with gauze soaked in Mer- 
cury bichloride solution, 1 to 1000, and bandaged on a finger 
splint. A new method is to cleanse the cavity and follow with 
an injection of a few drops of Carbolic acid, ninety- five per cent., 
which is allowed to remain in the cavity for one minute. The 
part is then flushed with pure Alcohol, which neutralizes the acid. 
The wound is then irrigated with the bichloride solution and 
covered with a wet dressing. If necrosis of a part of the phalanx 



ONYCHIA. 241 

develops, the pain will continue and an incision must be made 
down to the bone. 

Sometimes persistent treatment with injections of an iodoform 
oil, ten per cent., may save the bone which is often lost, but 
should not be removed until it has loosened spontaneously. 

If the tendons or their sheaths become infected restoration 
of function cannot be assumed unless the extensor tendons alone 
are involved, when a good result is more easily attained and a 
better prognosis can be "given. Infection of the flexors of the 
thumb and little finger may extend to the synovial sacs on the 
front anterior surface of the wrist, though if the first, second and 
third fingers are infected this is not so probable. 

Alumina, Asafoetida, Graphites, Hepar sulp., Mercurius, 
Natrum sulp. , Fluoric acid or Silicea will be indicated. Arnica is 
useful when a bruise is the cause of the affection, Mercury before 
pus forms, while Hepar sulp, and Silicea are indicated to hasten 
the formation and discharge of pus. 



ONYCHIA. 

An inflammation and ulceration of the matrix of the nail of 
the fingers or toes is termed ' ' onychia. ' ' The nail becomes dis- 
colored and is finally cast off. The affection generally arises 
from an infected injury, and is more commonly found in chil- 
dren as a simple inflammation about the root of the nail that goes 
on to pus formation. In time a new irregular shaped nail takes 
the place of the one diseased. The inflammation may become 
deep-seated and the ulcerations heal slowly. Then a dirty dis- 
charge and exuberant granulations are present, denoting a very 
unhealthy condition of the part. Necrosis often occurs. The 
condition is frequently due to syphilis. 

Treatment. — If pus has formed an incision should be made 
down to the matrix of the nail after the parts are rendered anaes- 
thetic by Ethyl chloride spray or a piece of ice held in contact 
with the skin. A small compress soaked in hot Bichloride of 
mercury solution or Salt solution should then be applied and re- 
applied often. The disease may be aborted if the finger end is 
16 



242 MINOR SURGERY. 

immersed in hot water for some time. The wounds should be 
kept clean, and exuberant granulations checked by applications 
of the Nitrate of silver stick or by curettage. Removal of the 
nail is at times indicated, as is also amputation of the finger. 

Syphilitic cases require antisyphilitic treatment. 

If the disease begins at the root of the nails give Causticum or 
Graphites, before pus formation Hepar sulp., after suppuration 
Silicea, under the nails Alumina, Causticum and Sulphur, all 
around the nails Alumina, Caust. , Hepar, I^achesis, or Mercurius. 

PALMAR ABSCESS. 

A suppurative process involving the tissues in the space just 
beneath the palmar fascia is termed ' ' palmar abscess. ' ' The 
symptoms are pain, heat, redness and swelling of the palmar and 
dorsal surfaces of the hand. 

Fluctuation is soon noted, and if the pus is not liberated it 
may break through the limiting membranes and rapidly destroy 
the adjacent tissues. Contraction of the fingers also occurs. 

Treatment. — Incisions made freely and early under the in- 
fluence of a local or general anaesthetic are indicated. Make one 
longitudinal incision through the whole length of the palmar 
fascia, care being taken to dissect slowly in order to avoid wound- 
ing the superficial and deep palmar arches, the base of the deep 
arch lying under the fascia at a level of the lower side of the 
thumb extended at a right angle to the index finger. 

The parts should be well cleansed and a rubber constrictor 
applied about the wrist so that hemorrhage will not blur the 
field. 

In some instances multiple incisions will be required, and these 
of course must be made with care. Drainage may be effected by 
placing a tube between the openings. 

If the case has been neglected it is often necessary to incise the 
dorsum of the hand where the swelling is very great and fluctua- 
tion can be felt. Ordinarily palmar incisions will suffice and the 
dorsal swelling subsides. The parts should be well cleansed with 
Hydrogen peroxide or Bichloride of mercury, solution i to 2000, 
and either drained by tube or packed with gauze pledges soaked 
in the Mercury solution or in Salt solution. 



WOUNDS OF THE PALMAR ARCH. 



243 



The dressing should be changed daily and the parts irrigated. 
As soon as the discharge begins to abate and granulation has 
begun, passive and active motion should be enforced, and the 
patient instructed to alternately flex and extend his fingers by 
light movements, and also frequently during the day he should 
produce different motions of the affected fingers with the aid of 
the other hand. 




Fig 61. Diagram of tendon sheaths of the hand. 

This is of importance, because the use of the member may be 
regained at an earlier period than would otherwise be the case. 
Hepar sulp., Silicea and Mercurius are always valuable in this 
affection. 

WOUNDS OF THE PALMAR ARCH. 



In a wound of the superficial palmar arch both ends of the 
divided vessel must be sought and tied, enlarging the wound if 
necessary. Wounds of the deep palmar arch often require the 
enlargement of the wound in order to get a good view of the 



244 MINOR SURGERY. 

parts, and this should be done in the direction of the flexor 
tendons, at the same time making counter pressure over the 
brachial artery. The divided ends should both be caught up by 
hemostatic forceps and tied off. If the artery can be caught by 
the clamps but cannot be tied over the point of the forceps, a 
hook may be used. Should these efforts fail to control the bleed- 
ing a small piece of sterile gauze may be packed into the wound, 
and over this several pieces, each slightly larger than its prede- 
cessor, until there is constructed a pad the shape of an inverted 
pyramid, the apex of which presses against the ends of the 
divided arch, and the base of which extends above the palm. 

Bach finger and thumb must be firmly bandaged, and a piece 
of metal is to be placed over the pad which is then bandaged 
rather tight. A compress of gauze should be placed in front of 
the elbow joint, the forearm flexed upon the arm and then a 
straight splint is applied to support the hand and forearm. This 
is held in place by a firm spiral reversed bandage that is started 
as figure of eight bandage at the wrist joint. 

The hand and arm are supported by a sling. The pad in the 
wound is not disturbed for a week unless the hemorrhage keeps 
up or recurs. Then it will be necessary to ligate the radial and 
ulnar arteries. 

Should this fail it is evident that the interosseous is supplying 
the blood and the brachial artery must be tied off at the elbow. 
Amputation of the hand is the last resort. 

The superficial palmar arch can be exposed through an incision 
extending from the junction of the thenar eminence towards the 
ring finger. 

The deep arch can be tied opposite the middle of the base of 
the thumb through an incision beginning at the junction of the 
thenar eminences and extending along the crease of the opponens 
pollicis toward the little finger. 

Of course it is imperative that extreme cleanliness should char- 
acterize all operative measures and other treatment. 

CONTRACTION OF THE PALMAR FASCIA. 

The palmar fascia and its digital prolongations may contract, 
and it is male patients, especially those beyond middle life who are 



CONTRACTION OF THK PALMAR FASCIA. 245 

afflicted by the deformity. The second, third and fourth fingers are 
the members most generally affected, though the thumb and index 
finger may become involved. The contracting process may go on 
for several years; the patient notices that the digit becomes more 
flexed upon the palm until the member is so bent that the finger 
nail is in contact with the palmal surface. Forcible extension is 
impossible, though the deformity and disability are painless. 
All the fingers on one hand may become deformed. If the palm 
is examined tense bands of fascia will be felt or seen under the 
skin, running to the sides or middle of the affected members. 
Persons of a gouty diathesis are more frequently affected, while 
injuries do not often excite the condition. A contraction of the 
plantar fascia similar to the palmar fascia rarely occurs. 

Treatment. — When the deformity is first noticed massage, 
passive motion and immobilization on a straight splint tend to 
restore the function and prevent further deformity. Usually the 
patient neglects to attend to the condition, and when they pre- 
sent themselves for treatment operative measures are required. 
A general or local anaesthetic is necessary. 

The contracted fascia and its prolongations must be freely 
divided by a small, sharp pointed knife inserted between the skin 
and fascia at different points. Each tense band should be divided 
by cutting upwards, and the wounds dressed with an aseptic 
dressing. 

The finger should be forcibly and fully extended and a splint 
applied. The members or member are dressed in extension and 
kept in this position for several weeks. The splints should be 
applied at night even when removed by the day. 

Another method is to dissect up a triangular flap of skin and 
then cut away the tense portions of the fascia. If this method is 
selected the apex of the flap should be in the palm over the 
prominent band of contracted fascia, while the base should be 
made far enough on the finger to give access to the lateral and 
median digital bands, which may extend as far as the second 
phalanx. When the fibrous ridges have all been clipped away 
the cutaneous flap is sutured in place. 

The subcutaneous method is generally successful and is to be 
preferred. 



246 MINOR SURGERY. 



TRIGGER FINGER OR LOCK FINGER. 

This is a condition that exists when extension or flexion is 
accompanied by a sudden stop in the motion followed by a jerk- 
ing resumption of movement. It is caused by part of the tendon 
being to large to slide freely in its sheath, which may be due to 
a small tumor or a chronic inflammatory swelling. 

The treatment is surgical, and consists in trimming the tendon 
on the side affected, and the removal of the small growth if 
present. 

Base ball players are often unable to extend the last phalanx 
of the finger because of the rupture of the attachment of the ex- 
tension tendons. This is best treated by an incision and sewing 
the small tendon to each side of the base of the phalanx. 

BLISTERED HEELS. 

Persons who are compelled to walk a great deal, policemen, 
postmen and soldiers, as well as those persons who wear heavy 
boots and rough stockings over unaccustomed heels, very fre- 
quently have blisters form on the heel of the foot. The blisters 
vary in dimensions, may be painful and limit the use of the foot. 

The treatment consists in cleansing the foot with soap and 
water followed by irrigation with Bichloride of mercury solution, 
1 to 2000. 

A useful instrument to evacuate the contents of the bleb is an 
ordinary sewing needle, which should be sterilized by passing 
several times through an alcohol or even a match flame. The 
needle is introduced at a point about a quarter of inch from the 
margin of the blister where the skin being somewhat thickened 
allows this to be done without pain. The needle is gently pushed 
until its point is beneath the raised epidermis. 

The needle is then withdrawn and slight pressure is made upon 
the blister which will express the contents through the channel 
made by the needle. 

If the procedure is carefully carried out there will be no danger 
of breaking the blister and exposing the raw surface. Occasion- 
ally the puncture may have to be repeated if the bleb should 



INGROWING TOE NAIL. 247 

refill. A few drops of contractile Collodion painted over the 
surface of the blister after it has been punctured will prevent its 
recurrence. 

INGROWING TOE NAIL. 

Ingrowing toe nail is rather a common condition and few little 
things cause more agony. 

The lateral borders t)f the nail become buried in or are over- 
lapped by the soft tissues. The affection is more often due to 
ill-fitting shoes that force the soft tissues over on the edges of the 
nail. 

An abnormal shape of the nail and a collection of a hardened 
cuticle under the nail that force it into the skin edges may also 
excite the condition. In addition to the pain, ulceration and a 
foul discharge result in neglected cases. 

Treatment. — In every case all pressure must be removed 
from the offending nail. This is best done by cutting out the 
entire toe of the shoe, while going bare-footed will effect a cure 
in man}^ cases. Palliative treatment consists in permitting the 
nail to grow outward, and, after scraping away the thickened 
cuticle beneath, to keep the square corner elevated by a small 
piece of cotton gently pushed under it. 

The ulcer should be touched up with the Silver nitrate stick. 
A method of treatment that has been of service in some cases con- 
sists of softening a piece of ivory or Castile soap in water and 
scrape gentty upwards so that the nail will be slightly raised by 
the soap accumulating underneath. The soap is allowed to 
remain till absorbed or pressed out, and the process is repeated. 
The soap relieves the pain by interposing an elastic cushion 
between the tender flesh and the nail, and at the same time 
soothes the inflamed tissues and softens the nail so that less 
pressure is exerted. 

The insertion of a piece of silver or tinfoil between the nail and 
the most tender point, and allowing it to remain until the ulcer is 
healed, is at times effective. The part is soaked daily in hot 
water and the foil reinserted. 

A good form of treatment is to disinfect the part with Peroxide 



248 MINOR SURGERY. 

of hydrogen, and then apply a piece of cotton saturated with a 
four per cent. Cocaine solution. When the part is anaesthetic a few 
drops of Monsell's solution are applied to the ulcer and the toe 
covered with gauze and bandaged. This is repeated every other 
day until the over-lapping tissue retracts and releases the nail. 
This application is not painful, and in forty-eight hours improve- 
ment is noted. Silver spring clips to fit over the edge of the 
nail on the affected side and raise it from contact with the ulcer 
are recommended. 

Operative measures are often necessary, and Anger's method is 
probably the best. The parts are scrubbed with soap and water 
and irrigated with Bichloride of mercury solution, 1 to 2000. 

The toe is encircled with rubber tubing or a tape to limit the 
action of the local anaesthetic and to control hemorrhage. 
Twenty drops of a two per cent, solution of Cocaine are injected 
into the diseased area, and in five minutes the operation can be 
commenced. An incision is then made through the length of the 
nail, about a quarter of an inch from the edge, beginning far 
enough up the toe to extend beyond the root of the nail. 

A transverse incision divides the matrix, and a third incision 
is made longitudinally through the inflamed and ulcerated tissues. 
The latter portion is then seized with forceps, and with a quick, 
firm pull drawn away. The ulcerated soft parts are then trimmed 
off or cauterized by a Nitrate of silver stick. 

Sutures of fine catgut or horse hair are introduced to bring the 
borders of the wound together, and an antiseptic dressing (Bi- 
chloride gauze) is applied. 

The patient can walk about after this operation, though better 
results will be obtained if the limb is kept quiet for two or three 
days. 

Fluoric acid, Hypericum and Silicea have a beneficial effect 
upon the soreness and irritation. 

HAMMER TOE. 

This condition is a flextion of one or more toes at the first 
interphalangeal joint. It is a trivial ailment, but is productive of 
a great deal of suffering. The deformity commonly begins in 



BUNION. 249 

childhood and becomes more pronounced at about puberty. It is 
due to contraction of the ' ' plantar fascia ' ' of the lateral liga- 
ments at the joint. The affection tends to progress slowly in 
spite of all precautionary measures. A simple flexion of the 
proximal phalanx occurs first, and this is followed by alterations 
of the bone, which cannot be returned to the normal position 
without fracturing the obstructing parts of bone. 

A contraction of the flexor tendons or weakening of the ex- 
tensors, contraction of the digital prolongations of the plantar 
fascia, wasting of the interossei muscles and ill-fitting foot wear 
are said to influence and cause the condition. 

Treatment. — Amputation is ordinarily the best method of 
cure, as tenotomy of the plantar fascia or flexor tendons is not 
effective, only adding the cicatrizing of the divided structures to 
the original difficulty. Excision of the flexed bone is perhaps 
the best means of treating the deformity. If the operation is 
carefully performed it leads to a nearly normal part and without 
a tendency to recur. 

This plan of treatment requires more time for convalescence 
than amputation. 

BUNION. 

A bunion is an inflammation of the normal or adventitious 
bursae of the toes. The metacarpophalangeal joint of the great 
toe is the part most usually affected. There is a chronic mal- 
formation of this joint, the toe is turned towards the median line 
of the foot and there is a subluxation of the joint inwards. 

Bunion is frequently caused by improperly fitting shoes, and 
also occurs often in persons who are upon their feet many hours 
of the day. As the pressure on the part continues the normal 
bursa becomes enlarged and inflamed, or an adventitious bursa is 
formed and this, too, is soon irritated. A corn may form in the 
skin covering the bunion, which increases the unpleasantness of 
the deformity. 

If prophylactic measures are not taken early, and the irritation 
to the joint is allowed to continue, the parts may become distorted 
to such a degree that a true hallux valgus will result. Bunions 



250 MINOR SURGERY. 

have been known to suppurate and leave a dirty looking ulcer, or 
a fistula which may penetrate the synovial cavity, causing inflam- 
mation of the joint with a loss of motion as a result. 

Treatment. — Prophylactic treatment consists in early removal 
of the cause and restoration of the deflected bones when possible. 
Young persons must avoid long, continued standing on the feet, 
and wear shoes with broad soles that do not press upon the meta- 
carpo-phalangeal joint of the great toe. When there is a tendency 
to flat foot a metal support may be worn inside the shoe to 
elevate the arch of the foot. An apparatus is made by manu- 
facturers of orthopaedic instruments that aids in the restoration 
of the deflected parts. Division of the muscles and ligaments 
which cause the displacement is practiced. If suppuration 
occurs the pus must be liberated by an incision at the spot where 
the pus seems to point. The cavity is washed out with Peroxide 
of hydrogen and packed with moist bichloride gauze, or the part 
may be flushed out with pure Carbolic acid in solution, and in 
turn irrigated with Alcohol which neutralizes the acid. The 
bursitis requires treatment by rest, hot air baths, elevation, hot 
water, lead and opium water compresses, or the same as recom- 
mended for bursitis. The simpler operative measures consist of 
the excision of the bursa or its subcutaneous division with a 
narrow tenotome. 

All operations about this or other joints should be attended by 
the most scrupulous cleanliness. 

If hallux valgus results the operative treatment consists of an 
elliptical incision made through the skin about three inches long, 
the concavity being below the mesial surface of the joint. The 
skin is reflected upwards, the joint opened and the ligaments 
divided or pulled aside. The first metatarsal bone is divided and 
a wedge shaped piece removed from it sufficient to allow the toe 
to be brought into proper position. If the head of the bone is 
deformed by overgrowth this should be cut or chiseled away. 
The synovial sac is sutured with fine catgut and also the skin 
flap. 

A longitudinal incision may be made instead of the elliptical 
cut, though the latter has the advantage of preventing pressure 
on the scar when the parts have healed. 






CORNS. 251 

The part should be placed in a plaster cast when dressed and 
not disturbed for three weeks unless symptoms arise that call for 
a change of dressing. 

Arnica, Hypericum, Graphites, Ruta, Hepar, Mercury and 
Silicea are often of much value. 

CORNS. 

A corn really is a form of papilloma and may be described as 
an abnormal development of the cuticle, together with an increased 
blood supply of the cutis beneath and an enlargement of its 
papillae. On the surface a corn is usually flattened and rather 
circular in shape, tending to become cone-shaped under the skin. 
The apex of the process is forced into the delicate papillae, and 
causes the discomfort so often noted. There are two varieties 
of corn, the hard and the soft. The hard corns are found, as a 
rule, on the backs of the toes, on the knuckles and occasionally on 
the soles of the feet, while the soft variety are found between the 
toes. The latter grow more rapidly than a hard corn because of 
the normal moisture that exists in this part. 

As is well known, corns are caused by pressure due to constant 
or occasional friction with ill-fitting foot wear or certain forms of 
daily labor. 

Treatment. — The treatment consists in, first, removing the 
cause, and second, in destroying the hypertrophy. 

Proper fitting shoes must be worn and by this manner relieve 
the existing irritation. When of recent origin the little growths 
will disappear, if,, when the cause is removed a felt corn- 
ring is worn whose edges prevent pressure by the shoe. Old 
corns must be soaked for several minutes in water as hot as can 
be borne and scraped with a clean corn knife. We know of a 
case where infection followed the use of an unclean knife with 
loss of the limb as a result. 

The corn should not be pared until blood exudes. Then ap- 
ply with a camel's hair brush, a mixture composed of the follow- 
ing: 

Fluid Extract Cannabis Indica, one-half drachm; Salicylic acid, 
one drachm: Flexible Collodion, one ounce. The corn should be 



252 MINOR SURGERY. 

soaked night and morning and the prescription applied twice 
daily. Old corns may have a bursa develop beneath them. If 
these become inflamed and suppuration occurs, the pus should be 
liberated with a clean knife after the parts are properly cleansed. 
Inflamed corns are best treated by rest and elevation and the ap- 
plication of gauze compresses, soaked in Goulard's Solution, a 
ceaspoonful to a pint of water. 

Soft corns should be painted with Venice Turpentine and 
cotton worn between the toes to absorb the moisture. Boracic 
acid powder is also of use. 

Calc. carb. or Sulphur should be given to eradicate the 
tendency to corns. 

SPRAINS. 

A sprain is an injury to a joint, a muscle or other soft parts by 
a wrench, a bend or a twist. There is always some laceration of 
the tissues, but generally there is no open wound. When a joint 
is involved the injury causes some tearing of the fibres of 
the capsular synovial membrane and the cartilages. If the 
sprain is at all severe there is an effusion into the joint; if the 
effusion follows immediately upon the injury it is blood, if it fol- 
lows twenty-four or forty-eight hours after the injury is received 
it is due to synovitis. This subcutaneous laceration has led to 
irrational treatment, in that the injured parts have been im- 
mobilized for too long a time. This procedure had in view the 
hope of rapid healing of the injured tissues, whereas it facilitated 
the formation of adhesions and aided in the waste of muscular 
tissue. 

Treatment. — The treatment of sprains and wrenches has for 
its object the restoration of the normal state by the rapid ab- 
sorption of the effusion, the prevention of adhesions, and the 
avoidance of muscle- waste. The plan of treatment personally 
used will be given in the case of a sprain involving the wrist 
joint. The injury is diagnosed from Colle's fracture and at the 
time, probably a few hours after the injury is received, there is 
considerable pain, the joint is swelled, due to the effusion, motion 
is limited and if attempted is resisted. 



SPRAINS. 253 

The first point in the treatment is the removal of the effusion. 
The part is well irrigated with water as hot as can possibly be 
borne. When practicable, the member is placed in the hot air bath 
and subjected to the high temperature for an hour. In many 
cases we have obtained the most excellent results in the treat- 
ment of all varieties of sprains, wrenches and bruises with hot 
air. After these measures the part is supported by a light splint 
and given gentle, smooth massage over the swelling. The pain 
is usually severe and will be resented by the patient, though the 
act may be accomplished if gentle strokes are given. The mass- 
age may be given three times daily by the attendant or the intel- 
ligent patient and when possible the hot air treatment is given 
twice a day. In the intervals of the rubbing, compresses wrung 
out in Lead water and Opium are laid upon the joint; the Opium 
allays pain and the Lead water hardens the skin a trifle, which 
is to be desired for subsequent manipulations. As soon as the 
effusion has commenced to subside, as is shown by the decrease 
in the tension of the part, gentle passive motions are commenced, 
and if, when the normal movements are resumed, no increase of 
effusion occurs the splint is no longer used. If the patient is 
seen early after the injury the splint need not be worn, as a gen- 
eral rule, after the third day. After the splint is dispensed with, 
gentle massage of the joint and adjacent structures is given and 
the range of the joint movements are increased; the massage be- 
ing more thoroughly given as the condition improves. 

In the case of knee-sprain the same principles are to be ob- 
served. The patient is sent to bed and a light posterior splint is 
applied. The hot air bath is indicated and shortens the con- 
valescence. From the very first, gentle passive motion of the 
patella is given. The joint is alternately flexed and extended 
when the effusion is decreasing. The points to be borne in mind 
being the avoidance of the use of splints after the effusion has 
begun to subside, the early use of massage and passive motion. 

In no case of sprain is a cure pronounced if there is any sign 
of muscular waste except that which results from non-use. The 
length of time between the receipt of the injury and the begin- 
ning of the given treatment influences the degree of muscle 
atrophy with its accompanying weakness and when the parts 



254 MINOR SURGERY. 

have been immobilized from first to last a good result is some- 
times doubtful and in all cases the healing is protracted. 

If the shoulder joint be affected the passive motions ought to 
consist of the antero-posterior movements, followed by abduction 
and adduction, which, in turn, are followed by rotary movements 
and circumduction. The same motions are gone through when 
the hip joint is involved. Where there is an external wound the 
mode of treatment may be somewhat interfered with. In such 
cases the adjacent parts should be well massaged. We wish to 
emphasize the value of hot air baths in every form of sprain. 
The excessive degree of heat has a beneficial effect upon the 
effusion. 

Sprains of the ankle joint occur with great frequency and are 
often important injuries. The majority of sprains involve the 
outer surface of the joint and the middle fasciculus of the exter- 
nal lateral ligament is the structure most frequently lacerated. 
Sudden tension of great force applied to the internal lateral liga- 
ment will often tear off a splinter of bone from the inner malleolus 
without producing laceration of the ligamentous fibres. Sprains 
of the ankle joint require immersion of the part in very hot 
water, the application of hot air or compresses of I^ead and 
Opium water. Gibney's dressing should be early applied. This 
dressing enables the joint to be used immediately and exerts a 
certain degree of pressure sufficient to aid in causing absorption 
of effused fluid in and about the joint. It also limits the motion 
so that further injury to the torn tisues will be prevented. 

The Gibney dressing is described as follows: "Strips of adhes- 
ive plaster are provided, an inch to an inch and a half in width. 
The first straps used are about eighteen inches long. The first 
is started about four or five inches above the malleolus on the af- 
fected side. It runs down by the edge of the tendo- Achilles, 
passes across the sole of the foot diagonally to the base of the big 
toe, if it is an external sprain, and to the base of the little toe if 
the sprain be an internal one. A number of these straps are ap- 
plied in the same way, each one slightly overlapping the last, 
until the whole outer (or inner, as the case may be) side of the 
ankle is covered. This having been done, another series of straps 
is applied as follows: The middle of the strap is placed at the 



SPRAINS. 255 

point of the heel, and the ends are carried to a point on the foot 
at the junction of the metatarsal bones and the tarsus; other 
strips are applied above this until the ankle joint is covered in. 
The whole is then covered with a neat gauze bandage, and if the 
dressing has been properly applied, the patient finds himself able 
to walk upon the injured foot, and should be encouraged to do 
so, at first to a limited extent only. If the patient is very fat or 
heavy, a wide strap passing under the sole and up along the side 
of the leg, nearly to the >knee, will act as an additional stirrup, 
and support the foot more firmly." The use of this dressing 
gives such good results that sometimes hardly anything else is 
needed, yet the use of passive motion and massage should 
never be neglected. 

This dressing can be reapplied whenever it becomes loose, due 
to the subsidence of swelling or when it is necessary to give mass- 
age. 

Oschner has devised a dressing that has for its aim the same 
results as the above dressing, though the plan of application is 
somewhat different. Oschner' s method consists in careful and 
systematic strapping with rubber adhesive straps. These are cut 
from one-half to three-quarters of an inch in width and the 
proper length. If a small ankle, they should be one-half inch 
wide; if a large one, they may be three-quarters of an inch, but 
no wider; on this and on the accuracy with which they are ap- 
plied depends the success of the method. If the straps are too 
wide, or if they are applied in a haphazard manner, failure is 
sure to result. The foot is held at slightly less than a right 
angle and a trifle everted; the former element in the position is 
observed because it is easier to walk on a painful ankle if it is 
held slightly in the equinus position; the latter element is ob- 
served because ankle sprains are usually caused by a sudden in- 
version of the foot, thus injuring the external ligaments; hence 
slightly everting the foot relieves the tension of these ligaments 
and places them at rest. With the foot in this position, one end 
of the strap is applied to the inner surface of the foot near its 
posterior end, and brought under the heel and up on the outer 
posterior surfaces of the leg to within a few inches of the knee. 
At the lower end this falls into the depression just posterior to 



256 MINOR SURGERY. 

to the external malleolus. A shorter strap is now applied by 
placing one end to the inner surface of the heel near the sole of 
the foot, then bringing it around over the tendo-Achillis to the 
outer surface of the foot, making it cover the first strap at a 
right angle and passing along parallel to the under border of the 
sole of the foot, then over the dorsum of the little toe. Another 
long one is then applied, anterior to the first, overlapping it 
about one- third of its width; then a short one, and so on 
alternately until the outer anterior aspect of the ankle is 
reached. Over all this a hard-rolled bandage is carefully and 
snugly applied. The patient is directed to lie still with the foot 
elevated until the warmth of the body has caused the plaster to 
adhere firmly. In a great majority of instances the patient can 
walk, with reasonable comfort, after a few hours. 

CHRONIC SPRAINS. 

Sprains or wrenches may be termed chronic when the part does 
not recover from the effects of the injury within a reasonable 
length of time. In healthy persons there are two reasons why 
sprains become chronic. In one the acute synovitis has not been 
recovered from because of improper use of the joint; and in the 
other the muscular atrophy and weakness may continue and be- 
come a cause of joint trouble. In the first class, where the in- 
flammation has not been entirely subdued, pain and partial loss 
of the use of the limb continue for perhaps several weeks. The 
muscles of the joint as well as the blood and nerve supply be- 
come affected and the part becomes swollen, painful and sensi- 
tive, with partial loss of function. These conditions may be 
found in any of the joints. 

The treatment of this class of chronic sprains requires that the 
inflammatory symptoms must first be calmed. If one of the 
larger joints be affected, complete rest and fixation of the part 
until the irritation of constant use has been recovered from. In 
the smaller joints slight use of the part is permissible. A daily 
hot-air bath is of great value and in three to five days of this 
treatment improvement will be noted. If there is malposition of 
the limb the joint must be brought to the normal. Gentle mass- 



SPRAIN-FRACTURE. 257 

age followed with more force when the excessive irritation has 
subsided is indicated as well as the limited but increasing use of 
the limb. Electricity, alternating douches of hot and cold water 
are good adjuvants. A good liniment is composed of Oil of 
cedar, Oil of hemlock, Camphor gum, each one drachm; Alcohol, 
four ounces. This combination should be rubbed on with brisk 
friction. 

In the second class of chronic sprains in healthy persons there 
may result a loss of muscular tone after the original joint affec- 
tion has been recovered from. This leads to a painful and some- 
what disabled joint. This condition may be due to too long im- 
mobilization of the joint during the acute sprain. The joint is 
painful and there is a distinct atrophy of the muscles. The 
treatment embraces hot-air baths, massage of all the adjacent 
muscles as well as the muscles involved, hot and cold douches, 
electricity and passive motion. As the cause is too long con- 
finement in one position, further restriction is contraindicated. 
Sprains become chronic and cause debility in some morbid con- 
ditions, such as rheumatoid arthritis, neurasthenia, tuberculosis 
and locomotor ataxia. 

SPRAIN-FRACTURE. 

This condition is due to an injury which separates a tendon or 
ligament from its point of insertion into a bone tearing off a 
splinter or thin shell of bone. As the treatment is the same as 
that of fracture, it is highly important that a proper diagnosis 
be made, though this is far from easy to do. Possibly the 
X-rays would aid. This injury is said to be rather common, 
and is probably often the cause of the so-called chronic sprain. 
The joints more commonly involved are the ankle, knee, elbow 
and wrist. 

Aconite, Arnica, Bryonia, Conium, Ruta grav., Hypericum, 
Rhus tox. and Kali jod. are the most valuable remedies, and 
under ordinary circumstances fulfill all indications of treatment 
in sprains. 



17 



CHAPTER XVIII. 



THE THORAX. 
CONCUSSION AND CONTUSION OF THE CHEST. 

The vital organs of the chest being protected as they are by 
their bony framework are less liable to receive mortal injuries by 
slight force applied to the chest wall. Non-penetrating chest 
wounds and injuries unaccompanied by fracture of the bones 
composing the chest walls are not, as a rule, of a serious nature. 
In some rare instances internal derangements have resulted be- 
cause of the external force, and unexpected complications follow. 
The rounded shape of children's chests and the elastic state of 
their ribs often prevent serious injury because they tend to roll 
or are pushed from beneath a wheel while fatal injuries might 
be given to an adult chest. 

The shock of chest concussion is not so great as the same de- 
gree of force applied over the abdominal viscera or to the cranium, 
though as a rule it is severe. If the internal organs are injured 
of course the shock will be greater. Laceration of the heart or 
lung, hemothorax, emphysema, pneumothorax, pleurisy with 
effusion and rupture of the diaphragm are some of the direct re- 
sults of simple concussion even when there has been no fracture. 
An excessively rapid respiratory function is frequently noted in 
children. This condition, while a part of the shock, lasts for 
some time after the ordinary symptoms of shock have been re- 
covered from. There may be sixty or seventy respirations a 
minute. The symptom is not so pronounced in adults and alone 
does not indicate a really serious condition. 

When called to treat a case of contusion of the chest with 
severe shock without external and evident internal injuries, no 
time should be lost to make a thorough examination. Shock 
must be actively combated from the very first. The patient 



INJURIES OF THE VESSELS OF THE CHEST WALE. 259 

should lie flat with the head lower than the body. Use hypo- 
dermics of Strychnia or Brandy, hot- water bottles wrapped in 
towels, hot cloths, the faradic current, artificial respiration and 
the injection of saline solution. Rectal enemas of strong coffee 
are also indicated. 

Fracture of the ribs with penetration of the pleura, wounding 
the lung or an intercostal artery may give rise to serious 
symptoms or even cause death. Haemo-pneumothorax is usually 
present, though there may not be an external wound. 

INJURIES OF THE VESSELS OF THE CHEST WALL. 

The intercostal and internal mammary arteries are subject to 
injury because of fractured ribs and sternum also different varie- 
ties of wounds. If there is no external wound or when the 
blood escapes into the pleural space one is apt not to recognize 
the presence of hemorrhage until the patient's condition denotes 
blood loss. The intercostals are the more frequently injured 
and an effort must be made to control the bleeding earl y. It is 
not easy to tie the bleeding point so recourse can be had to com- 
pression by packing the wound with sterile or antiseptic gauze. 
One should be careful that the blood does not continue to pass 
behind the compress into the pleural cavity. An intercostal artery 
is rather easily wounded by an incision close to the lower border 
of the sixth, seventh or eighth ribs in the anterior, lateral or 
posterior part of the chest. A good method of applying com- 
pression is to compress into the wound a square piece of sterile 
lint or gauze. The four corners are brought together so that a 
pocket is formed, which is tightly packed with lint. Thus the 
whole wound is well compressed. These cases must be given 
complete rest and carefully watched. If the hemorrhage con- 
tinues the wound must be freely exposed and the bleeding point 
secured. In many cases a resection of one or more ribs will be 
required so that the bleeding may be effectively controlled. 

Wounds of the internal mammary arteries are fortunately not so 
common as wounds of the intercostals. This injury is difficult to 
diagnose, treat, and is usually fatal. Any incised or gunshot 
wound near the border of the sternum must be carefully watched. 



260 MINOR SURGERY. 

The hemorrhage may be internal, because of pressure by a 
divided costo-cartilage. Hemorrhage from a wound of the inter- 
nal mammary artery calls for energetic measures for its control. 
Gay rand's method is to make an incision near the edge of the 
sternum that is directed outward at an angle of forty-five de- 
grees with the middle line. Its central point, over the inter- 
costal space where the artery is to be tied, should be a quarter of 
an inch from the edge of the sternum. Skin, subcutaneous 
tissue and pectoral muscle having been divided, the aponeurosis 
of the external intercostal muscle must be scraped through, and 
the artery will then be found, a quarter of an inch from the 
sternum. 

RESECTION OF A RIB. 

One or more ribs may require resection to control hemorrhage, 
in compound fractures, to liberate fluids within the chest and 
when the end of the bone has been pushed inwards wounding 
the pleura, lungs or other organs. Local anaesthesia will permit 
the operation to be performed without pain, though children and 
nervous individuals will have to take chloroform. When hemop- 
tysis is present local anaesthesia is all the more indicated. It is 
important to locate the bone inju^ by palpation and inspection. 
Sometimes the stethoscope applied over the fracture will reveal 
crepitation and so aid in locating the seat of injury. Of 
course the skin should^ be rendered aseptic, as should also the 
instruments and hands of the operator. If the patient be in 
shock it is good surgery to give a preliminary intra- venous injec- 
tion of the normal saline solution. The incision is made at right 
angles to the ribs and should be long enough to make the 
wounded region quite accessible. When the ribs are exposed the 
periosteum should be incised in the long axis of the rib which is 
the most injured. The outer surface of the rib is then stripped 
of its covering by a periosteal elevator, that is also passed be- 
tween the periosteum and the posterior surface of the rib, and in 
this manner separating the bone from its normal envelopment 
and also from the intercostal vessels. The elevator lifts the rib 
slightly and it is then divided with bone forceps or sawed 



ASPIRATION OF THE CHEST WALL. 26 1 

through. The size of the resected portion is determined by the 
operator. If the bleeding point is not discovered parts of neigh- 
boring ribs must be excised until the source of the hemorrhage 
is discovered. If there has been bleeding into the pleurae the 
cavity is opened after ligating any bleeding vessels, emptied of 
fluids and coagula by irrigation with the salt solution. Drainage 
tubes are then inserted within the pleura, the outer extremity 
being secured by pins and a liberal dressing of gauze applied. 
The greater portion of the external wound can be closed and as 
soon as the discharge from the cavity ceases and granulation is 
established the tubes may be removed. 

To drain the pleural cavities aspiration or incision and drain- 
age are necessary. Exploratory aspiration is more useful for 
diagnostic purposes. The incision is made, with the aid of a local 
anaesthetic, over the middle of the rib, which is usually the 
seventh or eighth, about four inches long in the region of the 
posterior axillary line. If there is sufficient space between the 
ribs to obtain proper drainage the pleura can be opened at once. 
If not, a rib must be resected. After the pleura has been opened 
the delicate adhesions between it and the lung are broken up 
with the aid of a buttoned probe. The pus is allowed to escape 
and the cavity irrigated with a warm five per cent. Caibolic solu- 
tion, which must be flushed out with a saline solution. Drainage 
tubes are inserted and the patient turned to such position as will 
secure the best drainage, and must occupy the same position the 
greater part of the time, even though the posture is unpleasant. 
In favorable cases the discharge lessens rapidly and the tubes can 
be removed by the end of the third week or even in less time. 
If the abscess be tubercular it is necessary to irrigate the cavity 
frequently, as the affection tends to become chronic. 

In the operation for empyema one must be careful to not in- 
jure the intercostal vessels which lie in a groove of the rib just 
within and above the lower edge. 

ASPIRATION OF THE CHEST WALL. 

Abnormal accumulations of fluid in the pleura include em- 
pyema, the ordinary effusion of pleurisy, the hydrothorax of 



262 MINOR SURGERY. 

cardiac, renal, malignant and tubercular diseases, chylothorax 
and hemorrhagic pleurisies. Each of these forms of effusion 
often require removal. It is highly important that the little 
operation be aseptic in every detail. The needle, skin and hands 
of the operator should be thoroughly cleansed. The point at 
which the needle is to be introduced is opposite the ninth rib, 
just outside the angle of the scapula. If the needle becomes 
blocked an effort should be made to clear it with a stylet. If 
this cannot be accomplished a fresh puncture is made. Rapid 
aspiration is dangerous, as it causes sudden fainting and also 
acute oedema of the lung. If faintness occurs during the with- 
drawal of the fluid the physician should stop at once and make 
the attempt at some future time. The puncture site can be 
closed with sterilized adhesive plaster or Collodion. Stimulants 
may be required at the completion of the operation. 

STRAPPING OF THE CHEST. 

Straps of adhesive plaster, properly applied, aid in limiting the 
motion of the chest wall when required for fractured and dis- 
located ribs, in contusions of the thoracic wall and in some cases 
of pleurisy. Usually it is only necessary to strap one-half of the 
chest, and for this purpose strips of resin plaster two and a half 
inches wide and long enough to reach from the spinal column to 
the middle of the sternum are required — the length depending 
upon the dimensions of the patient. The patient is instructed to 
expel the air from the lungs and the first strap is then applied. 
One extremity is placed upon the spine just posterior to the 
lower portion of the chest, while the other end is carried over the 
chest anteriorly and fixed to the skin in the middle of the 
sternum. The space above the initial strap is then filled in, each 
strap overlapping two-thirds of the preceding strap. Sometimes 
a second layer of straps may be required if additional fixation is 
necessary. A roller bandage snugly applied over the straps 
finishes the dressing, which may be renewed in a day or two if it 
becomes loosened. 



CHAPTER XIX 



THE ABDOMEN. 
INJURIES OF THE ABDOMEN. 

In contused wounds of the abominal wall, narrow bodies, 
trie action of which is exerted on a small area, reach deeper by 
overcoming resistance of the abdominal parieties more easily than 
larger bodies. The resistance varies with the age, state of 
obesity and state of relaxation or contraction of the muscles. 
The direction of the blow is of importance. If perpendicular to 
the deeper structures it is more harmful; when parallel it tends 
to glide off; when oblique the force is modified. There being 
often no external wound, the responsibility of the physician who 
first attends the patient is great. Very often an operation is im- 
perative to save life even before an exact diagnosis can be made. 
Blows upon the abdomen may affect the walls, the viscera, or 
both and are accompanied by more or less shock. A fatal result 
may follow without any structural lesion. Death may result 
from the most trivial injuries. 

Injury of the Stomach. — Rupture of this organ more often 
occurs in the anterior wall, and when the stomach contents 
escape the result is rapidly fatal. The symptoms include gastric 
pain, nausea and vomiting of blood, an anxious expression of 
the face and some restlessness. 

Rupture OF THE Intestixes. — Rupture is more often due to 
a crushing of the intestine against the lumbar spine, and a search 
should be made, in operated cases, back to the vertebrae. The 
s mall bowel is the seat of injury in seventy-five per cent, of all 
intestinal ruptures. Contusions of the bowel may cause perito- 
nitis even though gangrene or perforation are not present, due to 
the action of organisms, and lowered vitality. As a rule, shock 
reduces sensibility to pain. When the abdominal pain is severe 



264 MINOR SURGERY. 

and persistent and appears after the injury and shock has 
lessened, it is a reliable symptom of bowel rupture. Other 
symptoms include anxious facies, tenderness, persistent vomiting, 
absence of liver dullness and passage of blood per anum. 

Lesions of the spleen are indicated by collapse, increasing 
pallor and a feeling of suffocation; there is severe radiating pain 
in the region of the spleen. Chills are not infrequent and per- 
cussion shows the organ to be more or less enlarged. If exten- 
sive lesions occur severe hemorrhage and death result. 

Lesions of the kidney present general symptoms of abdominal 
traumatism, and in addition there is likely to be more severe pain 
in the lumbar region. This pain radiates in the direction of the 
pubes. Blood in the urine is an important symptom of renal 
injury. It is often followed by pus. 

Iyesions of the bladder, due to severe abdominal contusion or 
crushing, followed by inability to micturate, demand that a clean 
catheter be passed at once but with very great caution. The 
more important signs of vesical rupture include a peculiar pain 
felt at the time of the injury, urgent desire to micturate with 
complete inability to do so. The urine, if any can be obtained, 
is usually bright red. If the laceration is extensive the fluids 
will escape into the abdominal cavity. A free flow of urine may 
occur where there is a small tear. If there is doubt in regard to 
the nature of the injury, the physician should pass a sterile 
catheter and inject a Boracic acid solution (ten grs. to the ounce) 
into the bladder. If rupture has occurred, the bladder will not 
fill and rise above the pubis. Filtered air is sometimes used. If 
the solution of Boracic acid be used and one is unable to recover 
the full amount, there is probably an intra peritoneal rupture. 

Rupture of the gall bladder and biliary ducts, due to trauma- 
tism, give rise to severe pain in the right hypochondrium, vomit- 
ing of food and bile and icterus. Examination of the arine will 
reveal bile and the stools are clay-like in color. Tenderness over 
the hepatic region is a marked symptom. 

Treatment. — After a severe abdominal injury the patient 
passes through a stage of collapse; through a stage when the 
diagnosis remains uncertain; through a period when the symptoms 
of hemorrhage appear, and through a period of slow complica- 



WOUNDS OF THE ABDOMINAL WALL. 265 

tions. The attending physician should make every effort to com- 
bat collapse and attempt to make the patient ready for surgical 
treatment, which is, as a rule, positively demanded. Laparotomy 
is indicated to insure the patient adequate protection. The de- 
tails of technique for the various surgical procedures are beyond 
the scope of this book. 

WOUNDS OF THE ABDOMINAL WALL. 

Wounds of the abdomen may be classified as non-penetrating, 
when the walls alone are injured, and penetrating when the 
peritoneum is also wounded by the vulnerating body. Non- 
penetrating wounds vary in depth and length and are usually in- 
flicted by pointed, cutting or blunt instruments. When the mus- 
cles are cut, there is, of course, danger of future ventral hernia. 
Lesions caused by blunt bodies often cause severe shock or even 
death, due to laceration of the abdominal tissues. In the treat- 
ment of non-penetrating wounds of the abdominal wall, one 
should exercise care in the examination of the injured parts. If, 
by palpation, the condition of the viscera cannot be made out an 
aseptized finger may carefully explore the wound. Probes had 
better not be used because of the danger of converting the 
wound into a penetrating one. Hemorrhage is ordinarily slight. 
Of course, this should be effectively controlled and the wound 
cleansed and disinfected according to the directions given in the 
Treatment of Wounds. 

Cut muscular tissues must be brought accurately together by 
means of chromatized cat gut or silver wire sutures. Mattress 
sutures of silver wire will give firm support and very seldom 
cause further inconvenience. Sub-cuticular stitches of chroma- 
tized catgut may be used for the skin. If drainage is indicated 
capillary drains are alone to be used, as larger drains favor the 
formation of ventral hernia. The dressings of gauze and cotton 
are bandaged in place and the patient put to bed until complete 
repair of the wound has taken place. 

Penetrating Wounds. — In addition to local symptoms, 
wounds of this character give rise to progressive shock, nausea, 
vomiting, anxious facies, hiccough, intense thirst and restlessness. 
Certain organs, when injured, cause symptoms which are char- 



266 MINOR SURGKRY. 

acteristic of visceral lesions. Gunshot wounds are more fre- 
quently fatal than stab wounds, but stab wounds that penetrate 
the peritoneum are fully as dangerous as gunshot wounds. Not 
infrequently, cases of perforating wounds of the abdomen will 
recover without active surgical interference. The writer person- 
ally favors immediate operation as the best and wisest course to 
pursue in perforated, punctured, and gunshot wounds of the ab- 
domen. As this procedure belongs to the abdominal surgeon 
the physician had best be content with combating shock and ap- 
plying an antiseptic occlusive dressing. The dressings described 
under Wound Treatment will suffice. 

UMBILICAL HEMORRHAGE. 

This form of hemorrhage occurs from the navel in infants. 
It can often be controlled by pressure over a compress containing 
Tannin or Alum. It is sometimes necessary to pass a hair-lip 
pin under the navel and apply a twisted suture of either silk or 
catgut In severe cases the actual cautery is indicated. Fatal 
hemorrhage sometimes occurs. 

TAPPING THE ABDOMEN. 

This operation is often required to evacuate collections of fluid 
in the abdominal cavity, when the effusion is so great as to 
seriously embarrass respiration or the heart's action. There are 
certain precautions to be taken. The operator should have clean 
hands and a clean instrument. The puncture site ought to be 
scrubbed with soap and water and then with Ether or Alcohol. 
The patient's bladder must be emptied before the puncture is 
made. The point of entrance is determined after palpation of 
the abdominal wall. When a thoroughly dull spot is found the 
trocar can be gently introduced, care being taken that it does not 
enter too deeply. The fluid is then drawn off slowly. As the 
patient is liable to faint at times he had best lie near the edge of 
the bed, turned on his side. The operator must be careful to in- 
troduce his instrument in the middle line between the umbilicus 
and symphysis. Hemorrhage, wounds of the bowel and sepsis 
are possible unpleasant results. The external wound can be 
sealed with adhesive plaster or Collodion. 



CHAPTER XX. 



THE URINARY SYSTEM. 
CATHETERIZATION. 

A catheter is a hollow tube used chiefly to withdraw urine from 
and to wash out the bladder. Four kinds are in common use, 
viz., glass, gum, metal, and web, each of which has its distinct- 
ive advantages. They are various sizes and shapes of all the 
above materials, either variety being called for in certain condi- 
tions of the urethra. 

There are three most important virtues required in catheteriza- 
tion, thorough cleanliness, extreme delicacy, and much patience. 
The same principles are to be followed if, as occasionally occurs, 
the patients are instructed to catheterize themselves. 

CARE OF CATHETERS. 

According to Gouley, no catheter whose surface is fissured or 
otherwise roughened should be passed into the human urethra. 
For general use, physicians will find it advantageous to purchase 
the higher grades of web catheters, because, with proper care, 
they last long and retain their suppleness and smoothness. 

Web and rubber catheters are much injured by fats of all 
kinds, by Glycerine, by saliva, and by Vaseline. A watery 
solution of dry soap, with the introduction of some ingredient to 
add lubricity to its viscidity, is of value. The following is a 
modification of a formula for saponic lubricant: 

#. White Castile soap, powdered, i ounce. 

Water, 3 ounces. 

Mucilage of chondrus crispus, 3 ounces. 

Formalin (40 per cent.), 10 minims. 

Thymol, 5 grains. 

Oil of thyme, 5 minims. 

Alcohol, 15 minims. 



268 MINOR SURGERY. 

The soap and water are heated and stirred until an homo- 
geneous slime is formed; then the three ounces of Mucilage 
(made of the strength of one ounce of chondrus crispus to the 
pint of water) are added. When cool, the Formalin is poured in, 
then the Thymol and Oil of thyme mixed with the alcohol; it is 
then stirred, strained and kept in a covered vessel until all air- 
bubbles have vanished. The result, which is an opalescent, 
slimy substance, of the consistency of honey, should be put up 
at once in two-ounce collapsible tubes and sterilized. The lubri- 
cant is sufficiently viscid, adheres well to the surface of all instru- 
ments, does not lump, and is unirritating to mucous membranes. 

All web catheters are to be kept at full length and never 
coiled. They should be loosely wrapped in dry antiseptic gauze 
and preserved in tightly-closed metal cases until wanted for use. 
Before using a web catheter it should be sterilized in Formalde- 
hyde vapor and be momentarily immersed in warm Thiersch 
solution. After using, it is to be well washed by forcing a stream 
of water through the instrument, which is then dipped for a 
moment in Thiersch's solution. It should then be thoroughly 
dried, wrapped in antiseptic gauze, and enclosed in a metal case. 

Soft India-rubber catheters are also to be kept at full length, 
never coiled, and are to be wrapped in moist antiseptic gauze and 
preserved in tightly-corked glass tubes. Before using a rubber 
catheter it should be sterilized in Formaldehyde vapor and 
momentarily dipped in Thiersch solution warmed. Rubber 
catheters, when daily lubricated with fats, seldom last more than 
three or four weeks, then swell, lengthen, and become so soft as 
to be liable to be torn across during withdrawal. 

When it is possible to teach a patient the use of the catheter, 
perhaps the safest instrument that may be placed in his hands 
is the ' ' velvet-eyed ' ' India-rubber catheter, which he must 
cleanse thoroughly before and after its employment. 

Metal and glass catheters may be sterilized by boiling. Glass 
catheters may be kept in the antiseptic solution permanently. 

Aseptic Catheterism. — The surgeon should have in his kit 
catheters of the various shapes and sizes in order to deal with any 
abnormal conditions of the urethra. The prophylactic injection 
of a five-per cent, emulsion of Iodoform in Glycerine before the 



CARE OF CATHETERS. 269 

introduction of an instrument is advocated. If abrasion is caused, 
the Iodoform will come in contact with the wound at the very 
moment it is made. Iodine is set free, and by the chemical 
process thus formed bacteria are destroyed or their development 
arrested. 

A simple method of cleansing the anterior urethra is to irrigate 
the canal by solutions of Permanganate of potash, 1 to 3000, or 
Thiersch's solution previous to the introduction of the catheter. 

The following describes the technique of a normal catheteriza- 
tion : 

The patient may stand, sit or lie down, though the recumbent 
position is the better. The thighs are separated and slightly 
flexed. A fair sized rubber or web catheter is selected, made 
aseptic, warmed and lubricated. An ordinary glass syringe filled 
with sterilized olive oil which is injected into the urethra often 
aids in the passage. The operator holds the tube between the 
thumb and forefinger of his right hand. The little finger of the 
same hand rests upon the patient's abdomen at or just beneath the 
umbilicus. The catheter is inserted into the meatus and the penis 
is slipped over the catheter as far as it can be made to go. The 
catheter is then carried from its horizontal to a vertical position, 
when by pressing lightly downward and at the same time de- 
pressing the free end of the tube between the thighs of the pa- 
tient the instrument ought to pass into the bladder. When, 
however, after several gently repeated efforts fail the catheter 
can be withdrawn and the urethra again irrigated. An elbowed 
catheter should then be tried. The slight angle at the end of this 
instrument is of service, because it easily passes obstructions and 
keeps close to the upper urethral wall, which is important, as ob- 
stacles are found mainly in the lower and lateral walls of the 
urethra. 

If this fails to find the entrance of the bladder the double el- 
bowed catheter may be tried. Should the double elbowed catheter 
fail a soft rubber instrument of small calibre is slipped on one of 
the iron wire stylets with which English catheters are provided. 
The end of this wire stops one inch short of the eye of the 
catheter. By bending this wire a long curve is given the ca- 
theter, which is thus made rigid, but with a perfectly flexible 



270 MINOR SURGERY. 

end. The curve, rigidity and flexible end generally overcome ob- 
stacles and the tube passes into the bladder. In the event of this 
failing a long prostatic silver catheter should be used. 

The operator must be sure that there is an obstruction to the 
passage of the instrument, for the urethra is always lengthened, 
sometimes two or three inches, and the bladder may not be 
reached by the catheter. A physician should never lose his 
patience while working in the urethra, because of causing a 
possible false passage and lacerating the canal. Often a whale- 
bone guide or bougie can find the opening and if left in place the 
bladder will empty itself. Again, these same instruments will 
open the way so the catheter will find an entrance. A hot sitz 
bath is a valuable aid. If all these measures fail to relieve the 
condition supra-pubic puncture by means of a curved trocar and 
canula is indicated. This is a safe operation if done aseptically 
and is not hard to perform. It can be repeated very often with- 
out causing complications of any kind. The bladder is outlined 
and the region, needle and surgeon's hands cleansed. 

A puncture is made through the skin in the median line just 
above the symphysis pubis with a clean sharp knife. The aspi- 
rating needle is thrust downward and backward through this in- 
cision into the bladder. The lack of resistance will denote when 
it has penetrated through all the walls of this organ. The 
bladder may be partially or completely emptied. The needle is 
withdrawn, still keeping up the suction — so preventing infection 
of the puncture track with urine. If correctly done, the bladder 
may be aspirated three or four times a day for one or two weeks 
without unpleasant results. However, this measure is not to be 
encouraged when there is a chance to relieve the patient by other 
methods, and some means should be taken to secure permanent 
relief. If a stricture obstructs the urethra it should be dilated or 
removed, while if an enlarged prostate gland causes the retention 
this condition should be treated. 

RETAINED CATHETER. 

Retained catheter is often the best method of dealing with cases 
of retention of urine, particularly if the urethra is sensitive and 



URETHRAL INJECTIONS. 27 1 

the catheterization is complicated by bleeding, syncope, infection 
and fever. A catheter of good size should be chosen — the En- 
glish web preferably. The eye of the instrument should lie just 
within the internal vesical sphincter and must be kept open. 
Its free end should be kept under the surface of a 1 to 3000 Per- 
manganate of potassium solution held in a urinal so placed as to 
be beneath the level of the bladder. The urethra should be 
irrigated twice daily with the same solution. When the urine is 
sterile, the bladder need not be irrigated; when it contains pus or 
blood it should be washed two times daily. 

Continuous catheterization aids in the cure of chronic cystitis, 
in the passage of instruments and also relieves tension. The 
catheter is retained by passing threads around it immediately 
beyond the meatus and tying to tufts of supra-pubic hair. A 
better method is to fasten the threads to narrow strips of rubber 
adhesive plaster that are applied to either side of the penis and 
secured in place by two or three circular strips passing almost 
around the penis and a narrow gauze bandage. The threads at- 
tached to the catheter are passed through holes cut in the free 
ends of the first strips of plaster. The penis is then dressed with 
antiseptic gauze. A square of gauze made of ten or twelve 
layers is folded in the form of a triangle; the apex is secured to 
the catheter just beyond the meatus by a silk thread and rubber 
strap. Continuous catheterization may be kept up for from eight 
to sixteen days, when the catheter can be removed and the patient 
attempt to empty his bladder by muscular effort. 

URETHRAL INJECTIONS. 

In making injections into the urethra a hard rubber or glass 
blunt-nozzled syringe capable of holding four drachms is required. 
It is important that the point of the instrument is not sharp 
and so injure the mucous membrane when pressed firmly into the 
meatus. The patient may either sit or stand. He should first 
perform the act of urination, and the tip of the syringe is intro- 
duced within the meatus which is held apart by the thumb and 
index finger of the left hand. The syringe, properly cleansed, 
is filled and held between the thumb and middle finger of the 



272 MINOR SURGKRY. 

right hand, with the tip of the forefinger for pressing the piston. 
Pressure is made laterally with the left fingers upon the meatus 
against the tip and so narrows the opening, thus not allowing the 
fluid to dribble out. The piston is forced down into place slowly 
and gently and on the completion of the act the syringe is with- 
drawn and the meatus quickly compressed by the finger and 
thumb. Two or three drachms of solution should be used to dis- 
tend the anterior urethra. The injected fluid should be retained 
for three minutes, though some drugs to be effective are held in 
for five minutes or longer. Any solution which causes more pain 
than a slight smarting or fine needle prick sensation is very likely 
to irritate the sensitive membranes and so do more harm than 
good. This is of the greatest importance if good results are to 
be procured. Injections had best not be given during the course 
of an acute posterior urethritis or in acute anterior urethritis until 
the acute inflammation has been somewhat lessened with drugs. 
A patient may be directed to give himself injections after having 
been properly coached by the physician. In such an instance 
the patient should inject his urethra at first in the presence of 
the surgeon before performing the act at home alone. 

URETHRAL INSTILLATIONS. 

An instillator is a catheter-nozzled syringe which consists of a 
regular hypodermic syringe cylinder and a silver or hard rubber 
catheter with a short terminal curve. The instrument is steri- 
lized, and from five to thirty minims of the solution are drawn 
into the fine central channel. The tube is then lubricated 
with either aseptic Glycerine, Vaseline, Olive oil, Lubrichrondin 
or with the formula given under Catheterization. The next step 
is to insert the tip of the instrument until it passes the com- 
pressor urethrse muscle. The syringe is then emptied and the 
solution comes in contact with the membranous and prostatic 
portions of the urethra and flows backward into the bladder. 

The solutions in general use for instillations are Nitrate of 
Silver, Sulphate of Copper, Bichloride of Mercury, Iodine and 
Carbolic acid. Nitrate of Silver is used in a one per cent, solu- 
tion every third day and increased to a five per cent, solution. 



PASSING SOUNDS AND METAL CATHETERS. 273 

The other solutions are employed in strengths of one per cent, to 
ten per cent. The urethra should be well dilated with steel 
sounds or dilators before the instillations are made and should 
also be irrigated with a ten per cent. Boracic acid solution. The 
bladder should not be completely emptied, as the contained urine 
will dilute and neutralize the solution. 

Instillations are of value in the treatment of posterior ure- 
thritis where there are present such annoying conditions as tenes- 
mus, pain in the posterior urethra, painful erections and chronic 
posterior urethritis. 

PASSING SOUNDS AND METAL CATHETERS. 

The patient should lie on his back with the knees slightly 
flexed, elevated and separated. The operator stands at the left 
side of the patient and grasps the instrument, which has been 
previously sterilized and lubricated, in his right hand. The fore- 
skin is retracted, the organ and lips of the meatus steadied with 
the fingers of the left hand. The tip of the instrument is gently 
inserted into the meatus and into the urethra. At this stage the 
shaft of the instrument should be parallel toPoupart's Ligament. 
This is of importance in fleshy persons, in whom the tip of the 
instrument would be forced to catch against the anterior layer of 
the triangular ligament, because of the elevation of the handle 
made necessary by the prominent abdomen. Even in thin per- 
sons the shaft must be held low until the point enters the mem- 
branous urethra. The tip of the instrument having engaged, 
the penis is now drawn up onto the sound, which is gently forced 
in until three or four inches of the shaft is in the urethra. Then 
the handle is turned inward to the median line, the shaft being 
kept parallel to the anterior plane of the body and close to it. 
The shaft is now pushed downwards towards the knees, and as 
soon as this movement is arrested the fingers of the left hand let 
go their hold on the penis and are placed behind the scrotum onto 
the perineum, where the curve of the instrument is plainly felt. 
The handle up to this time has not been raised from the ab- 
dominal wall, but now it is elevated and passed slowly and with- 
out force over in the median line. When the shaft has passed the 
18 



274 MINOR SURGKRY. 

perpendicular the handle is taken in the left hand and the first 
and second fingers are placed on either side of the root of the 
penis and make downward pressure. The left hand then de- 
presses the handle between the thighs, so carrying the tip of the 
instrument through the deep urethra into the bladder. If this 
simple procedure is carefully observed in detail metal instruments 
can generally be passed into the bladder without much effort. 
Occasionally a few drops of blood follow the instrumentation 
and the following act of urination may be somewhat painful; but 
this is of no importance, and if gentleness and cleanliness have 
characterized the act such sequelae as orchitis, epididymitis, hem- 
orrhage, urethral fever and laceration of the canal will not occur. 
Instruments are removed in the reverse order in which they are 
passed. 

BOUGIES AND SOUNDS. 

Bougies are flexible instruments of various shapes and sizes 
used for diagnostic purposes, and also to find an opening into the 
bladder in cases of retention of urine due to stricture or other 
causes. Bougies are made of whalebone or hard rubber, and the 
instruments in common use are known as filiform and acorn- 
pointed bougies. The technique for the introduction of bougies 
is about the same as described under catheterization. Sounds, 
catheters and bougies are made according to certain scales. The 
American scale runs from i to 20; the French from 1 to 40, and 
the English from 1 to 12. 

Sounds. — These are solid steel instruments with a smooth sur- 
face and are nickel- plated. They are made in various sizes and 
shapes. Sounds are useful for dilating strictures of the urethra 
and in the treatment of pathological lesions of the deep urethra, 
prostate gland and seminal vesicles. There is no doubt that a 
sound is a much- abused instrument, and in incapable hands has 
done a great amount of damage. It is used altogether too often 
and should never be introduced unless indicated. Sounds may 
be sterilized in the soda solution, wiped on a clean towel and 
lubricated before being passed. 

A sound having a larger curve, known as a "stone searcher," 



IRRIGATION OF THE ANTERIOR URETHRA. 275 

is used in exploration of the bladder for calculus or tumor. 
When the point of the searcher comes in contact with the stone a 
peculiar click is often distinctly heard and is considered diagnos- 
tic. If a thin piece of board is attached to the handle of the in- 
strument the click will be magnified. The same sounds are pro- 
duced by the instrument grating against a vesical tumor encrusted 
with salts. 

PASSING THE FEMALE CATHETER. 

A glass catheter is often used for this purpose, though the 
ordinary flexible catheter is of equal value. Glass catheters have 
the advantage of being able to be thoroughly sterilized and when 
not in use can be kept immersed in an antiseptic solution. 

Modest persons and others formerly expected the physician to 
pass the tube under a sheet and thus avoid exposure. The diffi- 
culty of entering the orifice of the urethra increased the possi- 
bility of infection of the catheter and bladder, so modesty is now 
sacrificed for cleanliness. The vulva should be washed with soap 
and water and irrigated with Boracic acid solution. The labise 
are separated and the orifice of the urethra exposed. The cath- 
eter, sterilized and lubricated, is gently introduced into the blad- 
der. 

IRRIGATION OF THE ANTERIOR URETHRA. 

The modern treatment of specific urethritis, stricture of the 
urethra and diseased conditions requires that the canal be fre- 
quently irrigated. To do this effectively a Valentine Irrigator is 
exceedingly useful. The apparatus consists of a glass reservoir 
to hold the irrigation fluid (about one quart, which is usually 
Boracic acid or Permanganate of Potash, 1 to 3,000), or a rubber 
tube to the end of which is attached a glass nozzle with a blunt 
point. A stopcock regulates the flow and a metal shield prevents 
the fluid from flying back. An improvised irrigator can be made 
by placing the blunt nozzle into the tubing of an ordinary foun- 
tain syringe. The reservoir filled with fluid at a temperature of 
no or 120 degrees F. is raised about seven feet from the floor to 



276 MINOR SURGKRY. 

get proper hydrostatic pressure. The patient to be irrigated 
may lie down, or, if sitting, is placed far forward upon the edge 
of a chair seat. Clothing should be dropped to the knees and 
drawn over the abdomen. A rubber apron, with a hole for the 
penis, will protect the parts, and a bowl will catch the escaping 
fluid. The operator stands at the patient's right side and first 
cleanses the parts with cotton swabs soaked in Mercuric bichlo- 
ride solution, 1 to 3,000. This may also be done with the irriga- 
tion solution. The penis is grasped by the fingers of the left 
hand, while the right fingers operate the stopcock and nozzle. 
A thin stream is first allowed to run over the foreskin, glans and 
meatus. The foreskin is retracted and the meatus opened by the 
thumb and forefinger of the left hand. The stream is brought 
close to the meatus and the tip of the nozzle placed between the 
lips of the meatus, which is compressed about it. The fluid is 
permitted to flow in and out of the urethra, its posterior range 
being limited by the second, third and fourth fingers, which 
should grasp the organ firmly and contract the canal. When the 
reservoir has been about one-fifth emptied in the irrigation of the 
anterior third of the anterior urethra the second finger relaxes its 
pressure against the under surface of the canal, and in a minute 
the third finger is relaxed. The remainder of the fluid is used, 
pressure being maintained by the little finger. As a general rule, 
one reservoir of fluid is sufficient for the irrigation, though the 
treatment may be given from one to three times daily. 

IRRIGATION OF THE BLADDER. 

The technique of irrigation of the posterior urethra and the 
bladder is the same and will be described together. The patient 
may be placed in the same position as described for anterior 
irrigation and the same apparatus and fluids are required. The 
patient first empties his bladder and when in position the parts 
are irrigated and the nozzle placed into the meatus. The stop- 
cock is opened and the fluid allowed to run into the posterior 
urethra. As soon as the deep urethra is felt distending under 
the left finger tips the patient should be directed to take deep, 
slow inspirations and to attempt to urinate. The observance of 






IRRIGATION OF THE VAGINA. 277 

these points and the hydrostatic pressure will force the solution 
into the bladder. As soon as the organ is distended the nozzle 
is withdrawn and the patient empties his bladder into a urinal 
and the injection can be repeated. The average male bladder 
can hold with comfort about ten ounces of fluid, though from six 
to eight ounces is sufficient. 

The posterior urethra and bladder may be irrigated by passing 
a flexible catheter with a large opening at the side of the tip or 
a double catheter with a recurrent stream into the bladder. A 
rubber douche bag is filled with the warm solution and the tub- 
ing and nozzle attached to the end of the catheter. The solution 
is allowed to run into the bladder until the organ is well dis- 
tended or the patient may complain of a sensation of fullness, 
though care should be taken that the viscus is not over distended. 
When a sufficient amount has been gently ejected the stream is 
checked, the glass nozzle removed, and the bladder emptied by 
allowing it to run out of the catheter. The irrigation may be re- 
peated as often as the judgment of the surgeon dictates. In all 
cases it is important that the bladder be thoroughly emptied of 
the solution and in paralytic persons slight pressure over the 
region of the bladder will help to empty the organ. The bladder 
often requires irrigation in cases of chronic cystitis and to sterilize 
the organ previous to operations. The posterior urethra is 
washed out before the passage of instruments into the bladder 
and in the treatment of stricture and inflammatory conditions of 
the canal, prostate and seminal vesicles. 

IRRIGATION OF THE VAGINA. 

This organ is irrigated with the same fluids and by the ap- 
paratus described. The patient should lie on her back with 
clothes well drawn up in under to avoid soiling. A Kelly pad is 
placed beneath the buttocks to carry off the outflow. The vulva 
is first washed off and then the nymphae are separated by the index 
finger and thumb and the fluid allowed to flow into the vagina. 
An effort should be made to have the fluid come in contact with 
every portion of the vaginal mucous membrane. The introduc- 
tion of a vaginal speculum may aid in the thoroughness of the 
procedure. 



278 MINOR SURGERY. 

The glass nozzles recommended for use in irrigation must be 
carefully sterilized or infection is conveyed from one person to 
another. After use the nozzles should be boiled in water and 
Soda and rinsed in clean water and then placed in a receptacle 
containing Mercury bichloride, 1 to 1,000, where they should be 
immersed until again used. 

FOREIGN BODIES IN THE URETHRA. 

These consist largely of small calculi that are formed in the 
kidney or bladder or in the urethra itself and become caught in 
some narrow portion of the canal. Other objects, as bits of 
catheter, pins, pencils, matches, etc., are introduced by sexual 
perverts and often get beyond their reach. The irritation caused 
by the presence of the foreign article gives rise to pain, soreness, 
straining, swelling and a muco-sanquinolent discharge. There 
may be retention of urine. As there is a tendency for the article 
to slip back into the bladder it should be removed as early as 
possible. As a rule, the exact position can be ascertained by 
palpating the urethra from without by the fingers or from 
within by a well lubricated steel sound that is passed gently until 
obstruction or severe pain announce the location of the foreign 
body. 

The urethrascope is also of much service in determining the 
position. When located, the parts should be carefully manipu- 
lated and an effort made to advance the object toward the meatus, 
but if this fails an attempt should be made to grasp it with the 
fine jawed instrument known as the alligator forceps which are 
the best for the purpose. All efforts to remove the body should 
be characterized by gentleness for fear of lacerating the urethra. 
If the forceps are not effective it is best to make a small longi- 
tudinal incision in the median line down through the urethra and 
then remove the body. The cut must be made in the perineum 
or in the penile urethra according to the location of the foreign 
object. The wound should be sutured in two or three layers, 
care being taken that the suture does not enter the canal. A 
small flexible catheter is then passed into the bladder and retained 
for four or five days; the urethra during this time should be 



METHOD FOR INCREASING SIZE OF PENIS. 279 

irrigated four times daily with the salt solution or Boracic acid 
solution, five per cent. Rubber constriction placed about the 
penis may prevent the progress backwards, though should the 
object have entered the bladder it will be necessary to open the 
viscus by an incision made above the symphysis. If a pin has 
entered the urethra head first, a quick push will drive the 
pointed end out through the floor of the urethra and b}^ drawing 
the pin down as far as it will come, it can then be turned and 
pushed back with the -head toward the meatus where it is caught 
and withdrawn. If the object is a hairpin the ends of the pin 
are almost always pointed to the meatus. The penis should be 
squeezed to approximate the ends of the pin and then the opening 
of a silver catheter is slipped over the points to prevent their 
catching in the urethra walls. This action facilitates the 
removal of the body. 

Foreign bodies in the female bladder can often be easily 
removed after the dilatation of the urethra by the finger or by the 
introduction of a Kelly cystoscope. A blunt hook or wire snare 
aid in the removal of the object. 

METHOD FOR INCREASING SIZE OF PENIS. 

Varicose veins are at times found upon the penis and, as a 
rule, are of little pathological importance, though they may be 
accompanied by loss of power in erection. This may be due to 
the fact that the return flow is too great through the return 
veins, the dorsal and the lateral. Either one may be li gated. 
The operation can be done under Cocaine or Eucaine. An in- 
cision of one-fourth inch in length is made transverse to the vein 
and a sterilized silk ligature is passed under the vein with an 
aneurism needle. Both ends are brought up and tied. A stitch 
is put in the superficial tissues and an antiseptic dressing applied. 
The patient is then able to move about. The effect produced is 
a slower return of the blood and as a result a more permanent 
erection is produced and the blood being retarded, engorges the 
tissues and so enlarges the organ. 



280 MINOR SURGKRY. 



STRIPPING THE SEMINAL VESICLES. 

This procedure is indicated in chronic inflammatory conditions 
of the organs and is effected by introducing the index finger 
covered with a lubricated finger cot into the rectum, passing 
over the prostate gland until the seminal vesicles are reached. 
When distended they feel like whip cords and are easily recog- 
nized. The finger with the first phalanx slightly crooked makes 
firm pressure and is partially withdrawn. This is repeated sev- 
eral times until the tubes are emptied. The patient should 
stand, bending over the back of a chair, though should the treat- 
ment make him faint he may lie on the table with the thighs 
drawn up to a right angle with the body. 

The prostate gland is massaged in the same manner and for 
the same purposes described for the seminal vesicles. A per- 
forated, hard rubber tube has been devised to take the place of the 
finger during this treatment. The tube is attached to a water 
bag and a stream of water as hot as the patient can bear is al- 
lowed to run into the rectum upon the inflamed organs as the 
massage is being given. 

STRAPPING THE TESTICLE. 

The application of adhesive straps to the scrotum is indicated 
in some inflammatory conditions of the testicle. The patient lies 
on his back and the scrotum is supported. The upper portion of 
the scrotum of the diseased side is then grasped between the left 
thumb and middle or index finger, exerting sufficient pressure to 
confine the testicle to the bottom of the scrotum. A strip of ad- 
hesive plaster one-half inch in width is then made to encircle the 
constricted tissues below the grasp of the fingers. 

A second strap about three inches wide is next firmly applied 
around the testicle covering in the first constrictor. A third 
strip one-half inch wide is attached to the center of the perineal 
portion of the first strip, firmly drawn over the testicle and at- 
tached to the center of the anterior part of the first strip. An- 
other strip is placed from the first strip at the external surface of 



URETHRAL HEMORRHAGE. 28 1 

the scrotum to the median surface, at right angles to the first 
strip. Successive strips are placed in the same manner, each one 
slightly overlapping the adjoining. When the whole area is cov- 
ered in a final constrictor about six inches in length should be 
applied over the first set of straps. It is necessary to apply the 
straps smoothly and with firm and even pressure. It is best to 
wear a suspensory bandage and renew the dressing in forty-eight 
hours. 

URETHRAL HEMORRHAGE. 

Severe bleeding from the urethra may be controlled by Carle- 
ton's method, which is described by the author as follows: 

"A compress nine inches long and six in circumference, shaped 
like a policeman's short night club, is made of gauze wound 
firmly with a three-inch roller bandage. The scrotum is brought 
forward and upward on the penis, the testicles being allowed to 
fall on their respective sides. The compress is placed along the 
median line of the perineum, one end being at the anus, pressed 
firmly against the perineal, scrotal and penile portions of the 
urethra by an assistant, and a crossed perineal bandage applied 
to hold it with sufficient snugness to control the bleeding. 

Its advantages are self-evident. Immediate control of the 
hemorrhage; no blood can escape backward into the bladder or 
forward from the meatus; the degree of compression can be regu- 
lated by the surgeon; it can be easily removed to allow of urina- 
tion; the dangers of catheters, packing the urethra, urethral 
fever, etc., are avoided. 

In all cases after the first twelve hours, and in some earlier, a 
proper T-bandage can be substituted for the crossed perineal. 
This bandage should have an abdominal band eight inches wide 
to embrace the trunk below T the umbilicus, the upper pin holding 
it firmly above the crest of the ilium, the second or lower holding 
it about the hips. This gives a firm base. The perineal T should 
be nine inches wide, so that when it is brought forward and 
pinned to the abdominal band it will give sufficient pressure to 
the compress. This modified T-bandage has been found very 
satisfactory in all genito-urinary operations and dressings; it 
allows the patient much latitude of motion without danger of dis- 
placing the dressings or of the parts being unduly compressed." 



CHAPTER XXI. 



THE RECTUM. 
RECTAL BOUGIES. 

Special bougies are made to explore and treat certain patho- 
logical conditions of the rectum. There are several forms of 
bougies, but one made of red rubber and about twelve inches 
long is preferable. The Wales bougie has a central canal, through 
which the bowel can. be irrigated with various solutions. Several 
sizes are in use. Soft rubber bougies are to be preferred for dila- 
tation of the rectum, because much damage might result from 
the use of some of the mechanical dilators. 

The bougie must be well lubricated, and while the patient is in 
the recumbent position the tip of the instrument is gently forced 
into the bowel. When investigating the rectum with a bougie it 
is well to remember that there are two possible sources of error. 
In one instance the bougie may so double over that a miscon- 
ception of the length of the channel will arise, or the instrument 
may be arrested by one of Houston's folds and give the im- 
pression that a stricture has been encountered. Rectal bougies 
should be passed daily and left in place from five to ten minutes. 

FOREIGN BODIES IN THE RECTUM. 

The physician will be called upon to remove from the bowel 
foreign bodies which may have come from without or from 
within. Bits of undigested food, as bits of bone, may become 
caught in the folds of rectal mucous membrane and so cause 
ulceration and pain. Insane persons, children and sexual per- 
verts are known to introduce foreign substances into the rectum. 

Pain, bleeding and obstruction of the bowel are some of the 
symptoms of foreign bodies in the rectum. Sometimes the finger 



ENEMATA. 283 

can detect their presence. The rectal speculum will aid in the 
diagnosis and also in their removal. Ordinarily the body can be 
removed without anaesthesia, though should a general anaesthetic 
be employed the rectal sphincter can be stretched with the oper- 
ator's thumbs and the object removed with forceps or fingers. 

WOUNDS OF THE RECTUM. 

The anatomical position of the rectum allows the organ to escape 
ordinal accidental injuries. If there be a lacerated or incised 
wound the parts should be well examined, thoroughly cleansed 
with a stream of Bichloride solution, and an attempt made to bring 
the wound edges together. Chromatized catgut sutures should 
be introduced. When there is hemorrhage the source should be 
sought for and a ligature thrown around the spurting vessel. If 
there is a general oozing the application of gauze pledgets wrung 
out in hot water will probably stop the blood loss. A piece of 
one-half inch rubber tubing covered with layers of gauze will, if 
inserted into the rectum, very often stop blood loss. 

ENEMATA. 

The patient may be placed in Sim's position, the right lateral, 
the knee chest or the Trendelenburg posture. An evacuant 
enema consists of plain water, to which is added a little salt or 
soap-suds. One or two pints is a sufficient amount. All enemata 
are introduced slowly and by the aid of a fountain syringe or rub- 
ber douche bag. 

An effective purgative enema consists of, Ox gall, 15 grains; 
Turpentine, ^ ounce; Glycerine, 1 ounce; Castor oil, 1 ounce; 
soap suds, 1 pint. The Ox-gall should first be dissolved in a 
little warm water. Flatulence occurring during pregnancy is 
often relieved by injecting through a hard rubber syringe the 
following: Yolk of an egg; Turpentine, }4 ounce, well beaten 
together. In certain chronic inflammations of the intestines, in 
diarrhoea and hemorrhages from the bowel, an astringent enema 
is indicated. This may consist of Tannic acid, 10 grains; Tinct. 
Opii, 15 grains; Mucilage or Starch, 2 ounces; injected cold after 



284 MINOR SURGKRY. 

each defecation. A stimulating enema should be introduced 
through a rectal tube high up into the bowel. A good formula 
consists of, whiskey, ^ to 2 ounces; normal salt solution, ^ to 4 
pints. Strong coffee is much used. 

In flatulent colic an enema consisting of Mag. sulph., 1 ounce; 
Turpentine, ^2 ounce; hot water, ^ ounce, given high will often 
give relief. Nutritive enema are given to nourish the system 
through the bowels when nothing can be retained on the stom- 
ach. It is necessary that all food given per rectum should be 
pre-digested, contain salt and be warm. Small quantities often 
repeated are best. The rectum should be cleansed one hour be- 
fore the nutritive enema by flushing with two or three pints of 
warm soap suds. Inject high, from twelve to eighteen inches, to 
the sigmoid flexure, using the soft rubber rectal tube for adults 
and a soft catheter for children. The tubes should be lubricated 
with sweet oil or vaseline. 

If the patient lie on the left side with the hips elevated by a 
pillow and a soft compress retained against the anus for several 
minutes the food will be more easily retained. Where there is 
rectal irritability give five or ten drops of Tincture of Opium with 
the nutrient enema. 

To peptonize milk, chicken-broth or soup, beef -tea, oyster- 
broth or soup, or clam-broth or soup, one may use fifteen grains 
of Bicarbonate of Soda and five grains of Pancreatin to each pint 
of the fluid used. The powder is dissolved in a little water, then 
the fluid, which should be tepid, is added, and the vessel contain- 
ing this preparation is placed in a larger vessel containing water 
at a temperature of 90 F. The water must reach the margin of 
the food to be peptonized, which should remain in the water for 
exactly twenty minutes. If it remains longer or at a higher tem- 
perature it curdles and is unfit for use. After the food is pepton- 
ized it should be placed on ice and re-heated when needed. Lie- 
big's beef extract and Wyeth's beef- juice are very good agents, 
and do not need to be peptonized. 

The following prescriptions are valuable: 

Jfr. Either 
Milk, 
Chicken-broth, 



ENEMATA. 285 

Beef-tea, 
Oyster-broth, 
Clam-broth, 8 ounces. 

I*. Liebig's beef extract, 1 ounce. 
Hot water, 4 ounces. 
Whiskey, >£ ounce. 
Sodium chloride, 15 grains. 

#. Wyeth's beef-juice, 1 ounce. 
Tepid water, 1 ounce. 

This nourishment should, be repeated every three or four hours 
as needed. 



PART II. 



BANDAGING. 

Bandages are used to retain dressings in proper position, to 
hold splints in place in the treatment of fractures and dislocations, 
to make pressure and restore and maintain parts in their natural 
position which may have become displaced. 

The material used in the preparation of the bandage is deter- 
mined largely by the result desired. If the object is merely to 
retain a light dressing in position, then gauze makes the prefer- 
able bandage. Where moderate and firm pressure is desired, es- 
pecially if the dressing is to be kept moist, then ordinary flannel 
is to be preferred; but for all ordinary purposes unbleached mus- 
lin of not too coarse texture will meet the requirements. 

The usual form of bandage is known as the "roller band- 
age," and its size varies to meet the necessities of the case-. The 
strip from which the roller bandage is made should be free from 
seams and selvage, otherwise it cannot be so neatly applied, and 
if the bandage is used for the purpose of compression, is not so 
comfortable for the patient. This strip should be rolled into a 
cylindrical form to facilitate its application; this is accomplished 
by means of a special contrivance or by hand. 

It is well for every student and practitioner to be thoroughly 
familiar with the methods of rolling a bandage by hand so that he 
may be able to do it with neatness and despatch should the neces- 
sity demand the hasty preparation of one. The end of the strip 
of material to be used should be laid smoothly on the thigh in the 
direction of its long axis and then rolled over itself into a little 
cylinder by a sliding motion of the hand upon the the thigh; this 
movement may be continued till the bandage is rolled, or, in 
order to secure a firmer roll after the cylinder is about half an 
inch in diameter, it is grasped between the thumb and forefinger 
of the right hand and the unrolled portion is made to pass between 



BANDAGING. 287 

the extended thumb and forefinger of the left hand by means of 
the alternate supination and pronation of the right hand, the 
cylinder being held by the thumb and middle finger of the left 
hand, while the right is being pronated; the firmness of the roll 
will depend upon the degree of friction to which the loose por- 
tion is subjected as it passes between the thumb and index finger 
of the left hand. 

The pressure required to keep the bandage tight is very tire- 
some to the thumb and: for that reason it is desirable to be able to 
roll the bandage with either hand so that it may be changed 
from one hand to the other. If many bandages are to be rolled 
it is much better to employ a machine. Anyone with a fair 
amount of ingenuity, a piece of wire properly bent and a small 
box, can construct a bandage roller which will meet all re- 
quirements. In preparing the strips for baudages, keep in mind 
whether the bandage is to be used for the trunk or extremities, in 
order that it may be made of convenient size and will look neat 
when applied. In general practice a variety, comprising bandages 
for the head, trunk and extremities will be sufficient for the ap- 
plication of ordinary surgical dressings. 

For the hands, fingers and toes, a bandage one inch wide and 
three yards in length is desirable For head bandages and for the 
extremities of children, one two inches wide and six yards long. 
For the extremities of adults, one two and a half inches wide and 
seven yards long will be found more suitable, while bandages 
three inches wide and nine yards long are used more for the 
thigh and groin. For the trunk, bandages four inches wide and 
ten yards long are better. The skull cap or recurrent bandage of 
the head is very frequently called for ; it is used principally to 
retain dressings to scalp wounds of the top of the head. In the 
application of this bandage, either the single or double headed 
roller may be used. To use the double headed roller, stand at 
the back of your patient, hold a roller in each hand and place the 
intervening strip just above the eyebrows; now carry each roller- 
head backwards passing just above the ears till they meet 
posteriorly immediately below the occipital protuberance; here 
they cross at right angles, the inferior portion being carried up 
over the top of the head in the line of the sagittal suture to the 



288 



MINOR SURGERY. 



forehead; the other roller is carried horizontally forward; passing 
over the first portion, thus binding it down. The portion of the 
bandage passing along the sagittal suture is now reversed, passing 
back to the occiput a little to one side of the first strip, but slightly 
overlapping it; at the occiput it is crossed by the circular turn be- 
fore the reverse is made. This process is repeated, one roller be- 
ing carried from the occiput to the forehead then back to the oc- 
ciput, first on the right, then on the left of the first median strip, 
each of these strips being secured by a turn of the circular por- 
tion till the entire skull is covered; forming a complete skull cap, 
when both rollers are carried once or twice around the head, the 
ends finally being secured by a safety pin. The single roller may 
be used in much the same way; first, a couple of circular turns are 
made, then the bandage is reversed, passing over the head in the 
line of the sagittal suture: the recurrent folds are then applied the 
same as the foregoing, the extremities being kept from slipping 
by an assistant; finally two or three circular turns are made to 
steady the folds; to fix them more securely a few stitches or a 
couple of pins may be used. 




Fig. 62. Recurrent bandage of the head. 

This bandage can be made to look very neat, but the great ob- 
jection to it is, that in order to give it any security the confining 
turns must be drawn very tightly. If any portion of the wound 
falls directly under these circular turns, the pain caused would be 
very severe; in any case, this portion of the bandage is liable to 
interfere with the circulation of the scalp. 



BANDAGING. 289 

A bandage meeting all the indications of the foregoing and 
much easier of application, although not quite so neat appearing, 
is the six-tailed bandage. The material for this bandage should 
be about one yard in length and fifteen inches wide; now bring 
the ends of the bandage together, folding it in the centre; begin 
at a point three inches from each lateral border and cut directly 
towards the folded centre till within three inches of it; three inches 
to the inner side of these cut obliquely upward and outward on 
either side so that two^triangular pieces will be removed; this will 
give the six-tailed bandage, each tail being two inches in width. 
To apply, the centre of the bandage is placed directly over the 
vertex of the skull, the ends hanging at either side. The central 
ends are brought under the chin and tied; the anterior ends are 
drawn backwards, passing underneath the occiput and there tied; 
the posterior ends are brought forward and secured at the fore 
head, either by tying or pinning. 

In case of emergency, a splendid temporary bandage for injuries 
to the upper part of the head is the handkerchief or triangle of the 
head. The material for this bandage should be twenty-four to 
thirty inches square, then fold to a triangle. Place the bandage 
over the top of the head, with the apex of the triangle hanging 
over the face and the base under the occiput; now carry the ends 
of the base directly forward, crossing just above the eyes and 
passing back to the occiput where they are secured. The triang- 
ular portion is then carried directly upward and folded over the 
horizontal turns. 

For bandaging one eye a roller two inches wide and four yards 
long is used. The bandage is fixed by circular turns passing 
around the head from the occiput to the forehead; carry the roller 
back to the occiput, passing forward underneath the ear, crossing 
the angle of the lower jaw to the inner angle of the orbit; it then 
passes obliquely over the forehead to the parietal eminence of the 
opposite side, thence back to the occiput; a circular turn of the 
head is now made, passing just over the eyebrows; upon again 
reaching the occiput the roller is brought forward, covering in 
about two-thirds of the previous turn as it passes over the cheek ; 
these turns are repeated, the oblique alternating with the circular, 
till the eye is completely covered in; the bandage is finally com- 
19 



290 



MINOR SURGERY. 



pleted by making a circular turn and pinning. Where it becomes 
necessary to cover both eyes a modification of the preceding band- 
age will meet the requirements nicely. The roller should be two 
inches wide and six yards long. Fix the initial end of this band- 
age in the same manner as the preceding. After reaching the 
occiput, passing under the ear, across the cheek and over the 
parietal eminence to the occiput, make a circular turn around the 
head; upon reaching the occiput, instead of following the bandage 
as it passes under the ear, it should take a direction obliquely up- 
ward and forward, crossing the parietal eminence, passing over 
the junction of the nose with the forehead, downward over the 




Fig. 63. Crossed figure-of-8 bandage of both eyes. 

eye and cheek, below the ear to the occiput; a circular turn of the 
head is then made; upon reaching the occiput, following the 
course of the bandage as it passes upward over the cheek, each 
turn passing over an eye should alternate with a circular turn. 
These turns are repeated till both eyes are completely covered, 
the bandage being completed by a circular turn and secured by 
pinning. 

In cases of fracture or dislocation of the jaw, or to secure dress- 
ings to the chin, Barton's bandage is very serviceable. In apply- 
ing this bandage a roller two inches wide and six yards long is 
used. Beginning below the occiput, the bandage is carried ob- 
liquely upward and forward, passing in front of the parietal emi- 
nence, over the vertex of the skull, forward over the zygomatic 



BANDAGING. 



291 



arch, under the chin, upward over the opposite zygomatic arch, 
over the vertex of the skull, crossing the first part as near the 
center of the vertex as possible, back to the occiput; from here it 
is carried forward around the chin. Repeat these turns over the 
head and around the chin until the bandage is used or sufficient 
firmness is secured. In order to avoid the possibility of the band- 
age slipping introduce pins at each crossing of the bandage. 
Where such firmness is not demanded as is secured by the use of 
the preceding, the four-T:ailed bandage of the chin will be found 
very useful. The material for this bandage should be one yard 
long and four inches wide; from the middle of each end, tear it to 
within two and one-half inches of the center. Place the center of 




Fig. 64. Barton's bandage of the jaw. 

the bandage over the chin; now carry the upper ends directly back- 
ward to the nape of the neck and either secure them at that point, or 
cross them carrying obliquely upward and forward, securing in 
front of the forehead; the lower ends are then carried upwards 
over the temporo-maxillary articulation and secured on top of the 
head. 

The retention of dressings to the base of the neck or to the 
axilla is accomplished by the figure-of-eight bandage of the 
neck and axilla. A roller two inches wide and five yards long 
should be used. The bandage should be fixed by making one or 
two loose turns around the neck, carrying the roller from right to 
left, if it is to be applied to the left axilla; the reverse, if to the 
right; now carry the bandage over the shoulder, passing down in 



292 



MINOR SURGKRY. 



front of the axilla under which it is to pass, ascending behind, 
passing over the shoulder in front of and around the neck; these 
turns are repeated, each overlapping the preceding, until the de- 
sired space is covered. Care should be taken that this bandage 
be not too tightly applied, lest it impede the circulation. 




Fig. 65. Figure-of-8 bandage of neck and axilla. 



In applying bandages to the fingers, a roller one inch wide is 
used; the length will depend upon the number of fingers to be 
bandaged. The spiral for one finger will take a bandage one and 
one-half yards long ; for the gauntlet, four yards. To apply the 
spiral bandage of the finger, fix the bandage by two or three 
turns around the wrist ; then carry the bandage over the dorsum 
of the hand to the base of the injured finger proceeding to its tip 
by oblique turns. A circular turn is now made and then proceed 
with spiral turns from tip to the base of finger ; now carry the 
bandage obliquely over the dorsum of hand to wrist, making a 
circular turn when the bandage may be secured ; or the bandage 
may be carried to the base of another finger, enclosing it as in the 
preceding. This bandage was formerly used in the treatment of 
burns of the fingers to prevent the opposed raw surfaces uniting ; 
that indication is more fully met now by incasing each finger 
separately in a dressing and fixing a light dressing over the whole 
hand by a few recurrent and spiral turns of a bandage loosely 
applied. At present this bandage is used mostly in cases of frac- 
ture or dislocation of the phalanges or after an operation for web 
fingers. Where there is no danger of adhesions forming between 



BANDAGING. 



293 



the fingers and no special indication for producing compression of 
each finger separately, the spiral of the fingers and hand may be 
used ; this bandage has the advantage of being much more easily 






Fig. 66. Gauntlet bandage. 



Fig. 67. Demi-gauntlet 
bandage. 



Fig. 68. Spica 
of the thumb. 



applied and will maintain dressings to any part of the hand and 
wrist just as well. The material for this bandage should be three 
yards long and one inch and a half wide. The initial extremity 
is secured by two or three turns around the wrist; then carry the 
bandage obliquely across the back of the hand to near the finger 
tips ; now make a circular turn following this with ascending 
spiral turns till the base of the thumb is reached which may be 
covered in by either two figure of eight turns or the spirals may 
be reversed ; the latter will cover the base of the thumb more 




Fig. 69. Spiral reversed bandage of the upper extremity. 

completely. Upon reaching the wrist, the bandage may be 
secured by one or two circular turns and pinning, or if so desired, 
it may be carried to the elbow by spiral reversed turns. As the 
elbow is usually dressed in the semi-flexed position, it is covered 
in by a few figure of eight turns. The bandage may then cover 
in the arm by spiral reversed turns till the axilla is reached, 



294 MINOR SURGERY. 

thus enclosing the whole of the upper extremity. As this band- 
age is most generally employed in cases of fracture to secure im- 
mobility of the fragments, great care should be exercised in its 
application securing equal tension throughout so that unequal 
pressure will not be made thus interfering with the return circula- 
tion and favoring gangrene ; neither should the bandage be so 
firmly applied as to produce too great compression. 

The figure of eight bandage of the elbow, may be used as a 
part of the bandage of the upper extremity or may be used alone 
to confine dressings to the front of the elbow. In applying this 
bandage, the arm should be at right angles to the forearm. The 
initial extremity of the bandage should be fixed by two or 
three circular turns around the forearm about three inches below 
the bend of the elbow ; now carry the bandage obliquely upward 




Fig. 70. Figure-of-8 bandage of the elbow. 

in front of the elbow to a point two or three inches above the 
elbow joint where a circular turn is made around the arm ; it is 
then carried obliquely downward in front of the elbow and passed 
around the forearm overlapping two thirds of the initial turn. 
These turns are repeated, those around the arm descending, those 
around the forearm ascending, till the elbow is covered in, when 
it is secured by one or two circular turns. 

In cases of injury to the point of the shoulder, such as disloca- 
tion of the acromial end of the clavicle or for the purpose of re- 
taining the splint in position which is used in fracture of the upper 
end of the humerus the spica bandage of the shoulder meets all 
requirements. For the application of this bandage, a roller two 
and one-half inches wide and seven yards long is required ; where 
pressure especially is desired over the acromion process, the de- 



BANDAGING. 



295 



scending spica will give the best results. Fix the initial extrem- 
ity of the bandage, by one or two turns around the arm close 




Fig. 71. Spica of the shoulder. 

up to the axillary space ; now carry the bandage up behind the 
shoulder to the root of the neck, in front of the chest, under the 
opposite axilla across the back of the chest to the root of the neck 
crossing the first turn as near the root of the neck as possible, it 
then passes through the axillary space, following the course of 
the first turn overlapping it about two thirds, and descending 
toward the shoulder. These turns are continued until the shoulder 




Fie. 72. Recurrent bandage of a stump. 

is covered in, when circular turns are made around the arm and 
secured by pinning. The ascending spica is somewhat neater in 
appearance. This is applied by fixing the initial end as in the 
preceding ; now pass the bandage across the front of the chest, 
under the opposite axilla, across the back of the chest to the 



296 MINOR SURGKRY. 

starting point, passing around the arm up over the shoulder and 
following the course of the preceding turn overlapping it about 
two-thirds ; these turns are repeated until the shoulder is covered 
in when the extremity is secured by pinning. 

The Velpeau bandage is used to secure complete immobility of 
the upper extremity, as well as to form part of the dressing in 
fracture of either the coracoid or acromion process of the scapula 
or to hold the fragments of a fractured clavicle in position. To 
apply this bandage, two rollers each two and one-half inches wide 
and eight yards long are required. The patient should place the 




Fig. 73. Velpeau's bandage. 

fingers of the hand corresponding to the arm which is to be 
bandaged on the opposite shoulder near the root of the neck; now 
fix the bandage by making turns around the body, upon reaching 
the back, carry the bandage obliquely to the point of the shoulder 
on the affected side; passing downward on the outer and posterior 
part of the arm under the point of the elbow obliquely to the op- 
posite axilla, thence to the back. Instead of following the course 
of the first turn of the bandage proper, it now passes directly 
across the back over the flexed elbow around the thorax to the 
back and then follows the course of the first turn overlapping it 
slightly as it passes over the shoulder, these alternating turns are 
repeated till the upper extremity is firmly fixed. The transverse 
turns ascend from the point of the elbow, each covering in about 
one-half of the preceding, the last passing around the upper por- 
tion of the thorax and securing the wrist. 

The spiral bandage of the chest is used to retain dressings to 



BANDAGING. 297 

the chest or may be used where compression of the chest is de- 
sired. However, if too tightly applied, respiration may be seri- 
ously interfered with. For the application of this bandage, a 
roller two and one-half inches wide and nine yards long is used. 
From the top of the shoulder drop about two yards of the initial 
extremity of the bandage down in front of the chest; now carry 
the roller obliquely across the back to the opposite axilla, passing 
under the axilla; make a circular turn around the chest; close in 
the thorax, by means'of descending spiral turns till the waist line 
is reached, when the bandage is secured by pinning. Now pick 
up the initial end of the bandage which was dropped at first, and 




Fig. 74. Posterior figure-of-S bandage of both shoulders. 

carry it obliquely upward over the opposite shoulder from where 
it was dropped and secure the posterior spiral turns. The band- 
age should also be secured at the point where the first spiral 
overlaps the oblique portion on the back. The spiral turns will 
be retained in position by pinning them to the oblique portions 
over front and back. The anterior and posterior figure of eight 
bandages of the chest are employed to hold dressings to the ante- 
rior or posterior portions of the chest. Either of these bandages 
require a roller two and one-half inches wide and seven yards 
long. In applying the anterior figure of eight place the intitial 
end in one axilla; then carry the roller obliquely to the opposite 
shoulder passing in front of the chest over the shoulder through 
the axilla to the anterior portion of the chest; thence, to the op- 
posite shoulder, over and through the axilla. These turns should 



298 MINOR SURGERY. 

be repeated till the required support to the dressing is secured. 
The posterior figure of eight is applied by making the oblique on 
the back instead of the front of the thorax. For the purpose of 
maintaining dressings, poultices, or acting as a suspensory to the 
mammary glands, the triangle of the mamma will be found useful, 
both, because of its simplicity and ease of application. The 
material needed is a triangular piece of cloth, the base being one 
and one-fourth yards, and from base to apex eighteen inches; 
place the center of the base directly under the affected gland, 
carrying one end obliquely over the opposite shoulder; the other 
end should pass through the axilla of the affected side, these 
ends being tied on the back. The apex of the triangle is then 
carried upward over the shoulder of the affected side and secured 
to the bandage on the back. 

Where compression especially is desired use the compression 
bandage of the mammae. This bandage requires a roller two and 
one-half inches wide and eight yards long. The initial end is 
fixed by making one or two turns around the body, just below 
the mammae making the turn from right to left, if the left gland 
is to be bandaged, from left to right, if the right. After the 
initial end is secured pass the roller under the affected gland, ob- 
liquely across the chest to the opposite shoulder; thence diagonally 
across the back to the axilla on the affected side ; now make a 
horizontal turn, slightly overlapping the lower border of the 
gland. These turns should be repeated, each overlapping the 
preceding about one-half, the horizontal alternating with the 
oblique, till the gland is covered. 

Bandages designed to be applied to the lower. extremity, should 
be two and one-half inches wide and seven yards long. If one 
roller is not of sufficient length to meet the requirements, a sec- 
ond and third may be added. In applying a bandage to the en- 
tire lower extremity, fix the initial end by two or three turns 
around the ankle ; the roller is then carried obliquety across the 
dorsum of the foot ; now carry the roller around the foot just 
back of the toes, making two or three ascending spiral turns fol- 
lowing these by a few reverse turns ; now carry the roller obliquely 
inward and upward to the internal malleolus, around the heel, the 
center of this turn passing over the point of the heel, covering in 



BANDAGING. 



299 



the external malleolus ; thence to the inner border of the foot, 
around the sole and then following the preceding turn, overlap- 
ping it about two-thirds ; these turns are repeated till the heel is 
completely covered in. A couple of circular turns are now made 
around the ankle and these are followed by the ascending spiral 




Fig. 75. Spiral reversed bandage of the lower extremity. 




Fig. 76. Spica of the instep. 



Fig. 77. Figure-of-8 bandage of the ankle. 



reversed turns till the knee is reached. If the limb is to be 
dressed in a straight position, the knee may be covered in by cir- 
cular turns. These turns may be continued till the upper por- 
tion of the thigh is reached, when the bandage may be secured 
by pinning or it may cover in the hip by means of the ascending 
spica of the groin. 






300 



MINOR SURGERY. 



The spica bandages of the groin are serviceable in retaining 
dressings to, or making compression upon, the inguinal region, 
and as a temporary expedient will prove useful in retaining a 
hernia. After fixing the bandage by two or three circular turns, 
carried around the thigh, passing from the inner to the outer 
side over the anterior surface of the thigh, the roller is carried 
obliquely upward over the great trochanter, around the back of 
the pelvis to the anterior superior spinous process of the op- 
posite side ; thence obliquely downward over the lower portion 
of the abdomen to the outer side of the thigh, crossing the ascend- 
ing oblique turn directly over the center of the thigh. These 
turns are repeated, each covering in the preceding about one-half 




Fig. 78. Spica of the groin. 

till the groin is covered in when the bandage is finally secured by 
making one or two turns around the body and pinning. Addi- 
tional security can be given by inserting pins on either side where 
the circular turns meet the oblique. 

The figure of eight bandage of the knee is used where a dress- 
ing is to be applied to the knee alone, or it is used where compres- 
sion of the joint is to be made, and it is not desirable to dress the 
joint in the extended position. This bandage requires a roller 
four yards long and two and one-half inches wide. Fix the in- 
itial end by making one or two circular turns about three inches 
above the condyles of the femur, the turns passing over the an- 
terior surface of the thigh and from within outward. Now carry 



BANDAGING. 301 

the bandage over the external condyle, obliquely over the popli- 
teal space, to the inner border of the tibia; make a circular turn 
below the head of the fibula to fix the bandage below the knee; 
then carry the bandage obliquely upward over the popliteal space 
crossing the first turn in the center of the space. Repeat these 
turns, those above the knee descending, those below ascending, 
each overlapping the preceding about one-half till the knee is cov- 
ered in; last passing directly over the patella and secure by pin- 
ning. 

Immovable dressings are frequently required in the treatment 
of fractures to keep inflamed joints at perfect rest, after resections, 
etc. Many materials have been suggested for making an im- 
mobilizing dressing, but one which gives the best satisfaction and 
the one most generally used is the plaster of paris dressing. Care 
should be taken with the plaster used in the preparation of these 
bandages; if they have been prepared for some time it is more 
than probable that they have been exposed to the air and have ab- 
sorbed more or less moisture, which will interfere materially with 
the hardening of the bandage. By placing bandages suspected 
of being somewhat moist in a hot oven and allowing them to remain 
half an hour they will harden nearly as well as though freshly 
prepared. In the preparation of the plaster of paris bandage 
cheese cloth or crinolin is the preferable material, because of 
the wide meshes. The material selected should be cut into strips 
two and one-half inches wide and five yards long. The bandages 
should be loosely rolled, after rubbing dry plaster thoroughly 
into the meshes. In preparing any portion of the body for the 
application of the dressing it should first be covered by a soft 
bandage and the bony prominences protected by pads of cotton. 
If the plaster dressing passes over a part covered by short hairs 
it will be well to anoint that portion with vaseline to prevent the 
plaster sticking to the hairs. When all is in readiness the plaster 
bandage is submerged in water and allowed to remain until no 
more air bubbles are given off. The excess of water is then 
squeezed out. and the bandage applied to the part loosely, making 
just enough tension to have the bandage fit nicely. It is not 
necessary to make any reverse turns; any wrinkles can be 
smoothed out by rubbing the bandage with the hand, and, at the 



302 MINOR SURGERY. 

same time, the bandage will be more accurately fitted to the parts. 
A basin of plaster paste, of about the consistency of cream, 
should be at hand, so that it may be rubbed lightly over the com- 
pleted bandage, giving it a smooth finish, but it should not be 
applied too freely, for fear of making the dressing too heavy. This 
bandage can be lightened, and at the same time materially strength- 
ened, if a few strips of tin cut about an inch wide and nearly as 
long as the required cast be incorporated in the bandage. The first 
or protective bandage should be a little longer than the cast, so that 
when nearly completed the ends of this dressing can be turned 
back and secured by the last layer of the plaster dressing; this 
gives a finished appearance to the dressing. 

Before the finishing touches are completed it will be noticed 
that the cast is hardening, but it will not be perfectly dry for two 
or three hours. A little common salt added to the water with 
which the plaster is prepared will greatly hasten the hardening 
process. In cases of compound fracture or where a wound needs 
constant attention, it is advisable to make provision for a fenes- 
trum directly over the site of the injury. A pad of cotton over 
the wound will indicate the position for the fenestrum, and this 
portion of the cast can be removed and the edges smoothed with 
a little plaster paste. Should the injury be very extensive or 
should it be advisable to leave a joint exposed, then the two por- 
tions of the bandage can be united by an iron rod secured in 
each portion of the bandage. Various means have been devised 
for removing plaster dressings, such as placing a metal strip over 
the flannel bandage and allowing it to project a little beyond the 
plaster dressing; this can then be cut through over the strip 
without danger to the underlying parts. The most satisfactory and 
easiest method of removing these bandages is by means of chemical 
agents which act upon the plaster, producing softening, so that the 
bandages are easily cut through. A line painted with Hydro- 
chloric acid, vinegar or Hydrogen dioxide will produce this soft- 
ening of the plaster, after which the layers of the bandage can be 
divided with very little difficulty. 

A very convenient splint sometimes used in cases of fracture, 
especially where it is desirable to occasional^ remove the dress- 
ing, is found in the Bavarian splint. To prepare this splint take 



BANDAGING. 303 

two pieces of Canton flannel of sufficient length to enclose the 
injured limb and broad enough to slightly overlap when brought 
around the limb; the pieces should now be placed together and 
stitched lengthwise in the median line. The limb should be pre- 
pared as for a plaster bandage. Now spread the bandage out 
under the limb , the seam corresponding to the back of it ; the 
upper layer of flannel is then carried up and secured in front, 
either by pinning or by a few stitches. A plaster paste is 
now applied evenly and rapidly to the flannel surrounding the 
limb, taking care that the plaster does not pass over the edge of 
the flannel in front. The under layer is then brought around 
the limb, being moulded to it by the hands. A bandage loosely 
applied is now put over the splint, which holds it in position till 
the plaster has set. It can then be removed, the edges trimmed 
and bound, making it neater and more agreeable to handle. 

In the application of the plaster jacket, a tightly fitting undershirt 
free from wrinkles is used as a primary bandage. A folded towel 
is placed over the epigastrium, and in the case of females, a little 
cotton pad is placed over each mammary gland. The patient is 
now suspended by means of a special apparatus, consisting of a 
collar and arm pieces dropping from a cross bar. If this appara- 
tus is not at hand, a very good substitute can be had by apply- 
ing a Barton's bandage and securing a strip of bandage under the 
turns as they cross over the vertex ; this strip is attached 
to a stout wooden crosspiece about two and one-half feet in length; 
from either end of this crosspiece a support of some soft material 
is passed under each axilla. A rope from the center of the cross- 
piece is then passed through a pully or ring attached to the ceil- 
ing. Gentle traction is made till the patient's toes only are in 
contact with the floor. The plaster bandage is now applied as usual, 
smoothly and not too firmly, beginning just above the crest of the 
ilium and making one or two turns; it is then carried below the 
iliac spines and ascends gradually by spiral turns till the axilla is 
reached. These turns are repeated till a jacket of the required 
strength is secured. By placing a few strips of tin about an inch 
wide and as long as the jacket the strength will be greatly in- 
creased, and at the same time it will not be necessary to use quite 
so much of the plaster bandage, thereby diminishing the weight 



304 MINOR SURGERY. 

of the jacket. If the plaster has been free from moisture this 
bandage will harden in about fifteen minutes, during which time 
the patient should be kept suspended. If a little salt or alum has 
been dissolved in the water into which the plaster bandages were 
dipped, the hardening process is very much hastened. When 
completely hardened, if it is deemed advisable, the jacket can be 
removed, the edges bound, furnished with lacings and can then 
be removed and applied at will. 

Moulded splints can be easily prepared for any surface, by im- 
pregnating cotton with dry plaster; it is then dipped in hot water, 
applied to the desired parts, and retained in position till hardening 
has taken place, after which it can be removed, the parts inspected, 
and the splint replaced. 



INDEX 



Abdomen, injuries of, 263 

tapping the, 266 

Abdominal wall, non-pehetrating 

wounds of, 265 

Penetrating wounds of, . . . . 265 

Wounds of, 265 

Abscess, 171 

Alveolar, 188 

Aristol in, 173 

Belladonna in, 175 

Belladonna ointment in, . . . 172 

Boracic acid in, 173 

Calcarea carb. in, 175 

Cold compresses in, 173 

Definition of, 171-242 

Diagnosis of, 172 

Etiology of, 172 

Goulard's solution in, ... . 172 

Hepar sulphur in, 175 

Mercurial ointment in, . . 172 

Mercurius in, 175 

Nosophen in, - 173 

Otis' method of treatment, . .174 

Palmar, 242 

Peritonsillar, 186 

Peroxide of hydrogen in, . . .173 

Remedies in, 175 

Silicea in, 175 

Tinct. Iodine in, ...... . 172 

Surgical treatment of, . . . .173 

Symptoms of, 172 

Treatment of 172 

of neck, 212 

of the neck, tracheotomy in, 212 
of the neck, treatment of, . . 212 
of the Salivary. glands, . . . 208 
of the Salivary glands, treat- 
20 



ment of, 209 

of the Tongue 197 

Absorbent cotton, 30 

A. C. E. Mixture, 79 



73 

76 

191 

73 



Accidents from Anaesthetics, . 
from Chloroform, . . . 

from Extraction of teeth, . 
Occurring from anaesthesia 

treatment of, 

Acid, Carbolic, 20 

Aconite in burns, 157 

in Contused wounds, 146 

in Epistaxis, 217 

in Erysipelas, 169 

in Incised wounds, 145 

in Lacerated wounds, . . . 149 

in Nerve injuries, 233 

in Punctuied wounds, .... 147 

in Sprains, 257 

in Wounds of joints, 231 

Acquired tongue-tie, 196 

Actual cautery, 114 

Acupressure in hemorrhage, . . 61 

Acute bursitis, 236 

Adenoid growths, 218 

Diagnosis of, 218 

Symptoms of, 218 

Treatment of, ... . . 220 

Adherent tongue, 195 

Administration of anaesthesia, . 70 

of Chloroform, 76 

of Ether, 78 

After treatment of intubation of 

the larynx, 202 

of operations, 42 

of tracheotomy, 203 

Agents to procure asepsis, ... 20 



3o6 



INDEX. 



Agents to secure antisepsis, . 20 

Allen Surgical Pump, 107 

Alum in Epistaxis, . . . . , .214 

in Hemorrhage, 61 

in Umbilical Hemorrhage, . . 266 

Alumina in Felon, 241 

in Onychia, 242 

Alveolar Abscess, 188 

Belladonna in, . 

Calcarea earb. in, 

Hepar sulphur in, 189 

Mercurius in, 189 

Plantago in, 

Silicea in, 

Staphysagria in, 

Treatment of, 

American leech, 105 

Ammonia in shock, .... 67 

as a vesicant, 113 

Anaesthesia, General, 68 

Arsenicum after, 74 

Apomorphia after, 75 

Veratrum alb. after, 75 

Ipecac after, .... 74 

Nux vomica after, 74 



Bryonia after, 

Local, 

Anaesthetics, 

Accidents from, 

for Children, 

Anderson's method of tendon 

lengthening, 226 

Augiotribe, 61 

in hemorrhage, 61 

Anger's operation, .... 248 

Ankle, figure-of-eight bandage 

of, 299 

Anterior figure-of-eight bandange 

of Chest, 297 

Urethra, irrigation of, ... 275 

Anthrax, 169 

Definition of, 169 

Symptoms of, 170 

Antimonium crud. in Warts, . . 235 
Antiphlogistine, 135 



Antisepsis, agents to procure,. . 26 
Theory of, . 19 

Antiseptic poultice, . . . 137 

Operations, drainage in, . . . 44 
Operation, technique of, . . . 43 

Antithermoline, 135 

Apparently drowned, treatment 
of, 121 

Apis in erysipelas, 169 

Application of plaster of Paris 
jacket, , • . . 303 

Apomorphia, 222 

after Anaesthesia, 75 

Aristol, . 23 

in Abscess, 173 

in Burns, 156 

Arnica in bunion, 251 

in Burns, 155 

in Bursitis, 238 

in boils, . . . 165 

in Carbuncle, . ... 167 

in Contused Wounds, .... 146 

in Epistaxis, 217 

in incised wounds, 145 

in Nerve injuries, 233 

in Lacerated Wounds, .... 149 
in Punctured Wounds, .... 147 

in Sprains, 257 

in Tendon dislocation, .... 228 

in Tendon rupture, 228 

in Teno-synovitis, 230 

in Wounds of Joints, 231 

Artificial leech — Hourteloup's. . 105 
Respiration, Fell's method of, . 121 
Respiration, Howard's method 

of, 120 

Respiration, indications for . . 117 
Respiration, Laborde's method 

of, 119 

Respiration, Sylvester's method 
of, 118 

Arsenic in Cancrum oris, . . . 190 
after Anaesthesia, ...... 74 

in Carbuncle 167 

in Erysipelas, 169 



INDEX. 



307 



Arterial hemorrhage, 56 

Arteries, ligation of, 56 

Artery forceps, 58 

Ascending spica bandage of the 

Shoulder, 295 

Asepsis, Theory of, 18 

Agents to procure, 20 

Aseptic catheterism, 268 

Injections, technique of, . . . 92 
Operation, details of, ... . 38 
Operation in a dwelling room, . 45 
Operations, Materials used in, 25 
Operation, technique of, . . . 43 
Wax in hemorrhage, . . .60 

Asafcetida in felon, 241 

Aspiration, 93 

in Bursitis, 237 

of the Chest wall, 261 

technique of, 93 

Atropine in hemorrhage, .... 53 

in shock, ... 67 

Aurum in ganglion, 239 

Axilla, figure-of-eight bandage 
of, 291 

Bandage, Barton's, 290 

of the Eye, 289 

of the Fingers, 292 

Material used in, 286 

Roller, 286 

Bandaging, 286 

Barton's bandage, 290 

Bavarian splint, 302 

Beef tea enemata, 285 

Belladonna in Abscess, 175 

in Aveolar absces , 189 

Ointment in abscess, 172 

in Carbuncle, 167 

in Epistaxis, 217 

in Erysipelas, ..... 169 

in Post-operative Insanity, 128 

Beta Naphthol, 21 

Bi-chloride cotton, . . ... 31 

Preparation of, 31 

Bi-carbonate of soda in burns, . 155 



Bi-chloride of mercury, .... 21 
in Sinus, 175 

Birth mark, 115 

Bladder, irrigation of, 276 

Lesions of, 264 

Method of irrigating, .... 276 

Puncture of, 270 

Sterilization of, 36 

Blank cartridge wounds, treat- 
ment of, 152 

Blistered heels, 246 

Treatment of, 246 

Blood letting, 103 

Transfusion with, . . in 

Boils, 164 

Arnica in, 165 

Carbolic acid in, 165 

Constitutional Effects of, . . . 164 

Definition of, 164 

Hepar sulphur in, 165 

Mercurius in, 165 

Mono-sulphide of calcium in, 165 

Nitric acid in, 165 

Silicea in 165 

Treatment of, 164 

Boracic acid in Abscess, . . . .173 
in Corns, 251 

Boric acid, 23 

in wounds of the lids, .... 184 

Bougies, 274 

Method of passing, 274 

Rectal ... 281 

Brain, Wounds of, 179 

Breast, Compression Bandage of, 298 

Brush Burn, 158 

Arnica in, 159 

Calendula in, 159 

Hypericum in, 159 

Peroxide of hydrogen in, . . 159 
Treatment of, 159 

Bryonia after anaesthesia, .... 74 

in Epistaxis, 217 

in Tendon dislocation, .... 228 

in Teno-synovitis, 230 

in Sprains, 257 






3 o8 



INDEX. 



Bullet forceps, 151 I 

Krag-Jorgensen, . . . . . 149 

Lee-Metford, 149 

Mauser, 149 

Bunion, 249 

Arnica in, 251 

Graphites in, 251 

Hepar sulphur in, 251 

Hypericum in, 251 

Mercury in, 251 

Rutain, 251 

Silicea in, 251 

Treatment of, , . 250 

Buried suture, 140 

Bursitis, 235 

Acute, 236 

Aspiration in, . . . . . 237 

Arnica in, 238 

Graphites in, 238 

Hypericum in, 238 

Hepar sulphur in, 238 

Incision in, 236 

Iodoform emulsion in 237 

Mercury in, 238 

Ruta in, ..... 238 

Silicea in, . . 238 

Symptoms of, 236 

Treatment of, ... . 237 

Veratrum vir. in, 238 

Burns, Aconite in, 157 

Aristol in, 156 

Arnica in, 157 

Bicarbonate of soda in, . . 155 

Cantharis in, 157 

Carbo veg. in, 157 

Causticum in, 157 

Cocaine ointment in, .... 155 

Coffea in, 157 

Constitutional effects of, . . . 154 
Continuous warm bath in, . . 157 
Calcined magnesia in, ... . 155 

Camphor in, 157 

Carrion oil in, 156 

Due to chemicals, 161 

Electrical, 159 



Burns, Europhen in, 156 

Flexible Collodion in, . . . . 155 

Iodoform in, 156 

Picric acid in, ... . . 155 

Potassium nitrate in, 156 

Rhus tox. in, 157 

Turpentine in, 156 

Veratrum alb. in, 157 

Treatment of, . 154 

Powder, 158 

X-ray, . . 161 

Burns and scalds, 154 

of the Tongue, 197 

of the Tongue, symptoms of, . 198 
of the Tongue, treatment of, . 198 

Button suture, T40 

Cactus in epistaxis, 217 

Calendula in Brush burn, . .159 

in lacerated wounds, 149 

in Tendon dislocation, . . . 228 

in Tendon rupture, 228 

in Wounds of Joints, 231 

Calcarea carb. in abscess, . . . .175 

in Alveolar abscess, 189 

in Corns, 251 

in Ranula, 188 

in Warts, 235 

Calcined magnesia in burns, . . 155 

Calculi, salivary, 187 

Calmette's antiveuene, 152 

Camphor in burns, 157 

Camphor gum in chronic sprains, 257 
Cannabis Indica in Corns, . . .251 
Cancrum oris or Noma, .... 189 

Arsenic in, 190 

Carbo veg. in, 190 

Oil of Cassia in, 190 

Oil of Gaultheria in, .... 190 

Hydrastis in, 190 

Mercury in, . . 190 

Staphysagria in, 190 

Symptoms of, 189 

Treatment of, 189 

Cantharis in burns, 157 



INDEX. 



309 



Cantharis cerate, 113 

Cantharidal collodion, .... 113 

Cap, skull, 287 

Capillaries, operations on, . . .115 
Capsicum as a rubefacient, . . .112 

Carbolic acid, 20 

in Boils, 165 

in Erysipelas, 168 

in Felon 240 

as a Local anaesthetic, .... 86 

Carbo veg. in burns, 157 

in Cancrum oris, 190 

Carbuncle, . 165 

Arnica in, 167 

Arsenicum in, . . . ... 167 

Belladonna in 167 

Definition of, 165 

Echinacea in, 167 

Lachesis in, 167 

Rhus tox. in, 167 

Silicea in, 167 

Treatment of, 166 

Symptoms of, 166 

Carbuncle of the lip, 185 

treatment of, 185 

Carleton's method of treating 
urethral hemorrhage, . . . 281 

Carrion oil in burns, 156 

Castor oil enemata, 283 

Catgut, 26 

Chromicized, . 27 

Cumol, 27 

Ligature, 28 

Suture, • ... 28 

Catheter, 267 

Care of, 267 

Glass, 267 

Gum, 267 

Metal, 267 

Retained, 270 

Rubber, 268 

Web, 267 

Catheterism, Aseptic, 268 

Continuous, 271 

Technique of, 269 



Cathetherization, 267 

Causticum in burns, 157 

in Ganglion, 239 

in Onychia, 242 

in Warts, 235 

Causes of Retro-pharyngeal ab- 
scess, 217 

of Rhinoliths, 214 

of Teno-synovitis, 228 

Cautery, actual, 114 

in Epistaxis, 214 

Paquelin's, 114 

Cauterization, for hemorrhage, . 60 
Cerate cantharis, ...... . 113 

Cerebral hemorrhage, 31 

Chest, anterior figure-of-eight 

bandage of, . . 297 

concussion of, 258 

Posterior figure-of-eight band- 
age of, 298 

Spiral bandage of, 296 

Strapping the, ....... 262 

Chest wall, aspiration of , .... 261 

Chiene's incision, 218 

Chilblains, 126 

Chicken broth enemata, .... 284 

Children, anaesthetic for 79 

China in epistaxis, 217 

in Wounds of joints, . . . .231 
Chromatized catgut, . . -27 

Chromic acid in epistaxis, . . .214 

Chronic sprains, 256 

Camphor gum in, 257 

Electricity in, 257 

Oil of Cedar in, 257 

Oil of Hemlock in, 257 

Treatment of, 256 

Chloroform, 75 

Accidents from, 76 

In hemorrhage, 61 

as a Vesicant, . . . 113 

Chloretone, 85 

Chloride of ethyl, 85-86 

Chromic acid in Warts, .... 234 
Clam broth enemata, 285 



3io 



INDKX. 



Clothing of operator, 33 

Coal miner's elbow, 236 

Cocaine, disadvantages of, . . . 83 
Hydrochlorate of, ..... 82 

Ointment in burns, 155 

subarachnoidean injections of, 86 

Coffea in burns, 157 

Collodion. Cantharidal, . . . .113 

Cold compresses, 135 

in Abscess, 173 

in Wounds of the Ivids, . . .184 
Complications in cut throat, . 210 

Compressed moss, 31 

Compresses, 31 

cold, 135 

hot, 135 

in hemorrhage, . . . . 59 

Compression bandage of the 

breast 298 

Concussion and contusion of the 

chest, 258 

treatment of, . . . 258 

Conium in sprains, 257 

Conjunctiva, wounds of ... . 183 
Constitutional effects of boils, . 164 

of burns, ... 154 

of hot dry air baths, 102 

of hemorrhage, . . . . 53 

Continuous catheterism, . . . .271 

suture, 138 

warm bath in burns, 157 

Contraction of the palmar fascia, .244 

treatment of, 244 

Contused wounds, 146 

Aconite in, ... 146 

Arnica in, 146 

Treatment of, 146 

of the scalp, 177 

Corns, 251 

Boracic acid in, 251 

Calcarea carb. in, ..... 251 

Cannabis Indica in, 251 

Definition of, 251 

Goulard's solution in, . . . .251 
Salicylic acid in, 251 



Corns, Sulphur in, 251 

Treatment of, 251 

Venice turpentine in 251 

Cotton, • . . . 30 

gloves, 35 

Sterilized, 31 

Counter irritation, 112 

Cumol catgut, 27 

Crocus in epistaxis, 217 

Cupping, 107 

Dry, 107 

Wet, 107 

Cut throat, 210 

Complications in, 210 

Treatment of . . • 210 

Cysts, sebaceous, 235 

Czerny's method of tendon leng- 
thening, 227 

Dam, rubber, 29 

Dangers of transfusion of blood, .111 

Deep incisions, 105 

sutures in hemorrhage, .... 60 

Definition of Abscess, 171 

of Anthrax, 169 

of Bunion, . . „ 249 

of Carbuncle, 165 

of Corns, 251 

of Erysipelas, • 167 

of Onychia, 241 

of Palmar Abscess, 242 

of Phlegmon, • . 170 

of Sinus, 175 

of sprain, 252 

of Warts, 234 

Demi-gauntlet bandage of the 

hand, 293 

Details of aseptic operation, . . 38 

Diagnosis of abscess 172 

of adenoid growths, 218 

in Unconsciousness, 131 

Diday's operation, 234 

Digitalis in hemorrhage, . ■ • • 53 
Digital compression in hemor- 
rhage, 55 



INDEX. 






Dilated vessels, subcutaneous lig- 
atures in, 116 

Dissections, -39 

Dissection wounds, . . 144 

Disadvantages of cocaine, . 83 

Dislocation of muscles 228 

treatment of, ... ... 228 

of tendons, 228 '' 

treatment of, 228 

Dog bite, w .... 152 

Drainage, 28-41 

In Antiseptic operations, ... 44 | 

Horse hair in, 28 | 

tubes, .28 

of Wounds, 51 

Dry dressings, ....... 29 

Dressings immovable, . . . . 301 

Plaster of Paris, . . . . 30 r 

Wet, 29 j 

Dressing Powder, 42 

Dry cupping, . . 107 

Dulcamara in Warts, 235 j 

Dwelling room, aseptic operation 

in, • 45 i 

Ear, foreign bodies in, 207 

Echinacea in carbuncle, .... 167 
Elastic bandage in teno-synovitis, 229 
Constriction in hemorrhege, 55 
Elbow, figure-of-eight bandage of, 294 1 

Coal miner's, 236 

Electrical burns, 159 

Prognosis of, 160 ■ 

Shock in, 160 ' 

Syinptoms of, r 59 

Treatment of, j 60 ; 

Electric needles, 115 

in Treatment of warts, .... 234 
Electricity in chronic sprains, . . 237 

injuries due to, 162 

in nerve injuries, 232 

Encephalitis, 179 

Enemata, 283 

Beef tea, 285 

Clam broth, 285 

Milk, 284 



Enemata, Nutrient, 284 

Oyster broth, 285 

Wyeth's beef juice, . . 285 
Whiskey 285 

Epileptic convulsions 132 

Treatment of, 132. 

Epistaxis, 214 

Aconite in, 217 

Alum in, 214 

Arnica in, 217 

Bryonia in, 217 

Cactus in, 217 

Causes of, 214 

Cautery in, 214 

China in, 217 

Chromic acid in, 214 

Crocus in, 217 

Gauze tampons in, 214 

Hamamelisin, 217 

Melilotus in, 217 

Phosphorus in 217 

Pulsatilla in, 217 

Sepia in, 217 

Suprarenal extract in, . . . .216 

Tannic acid in, 214 

Treatment of, 214 

Ergotine in hemorrhage, . . 53 

Erichsen's ligature, 116 

Erysipelas, ... 167 

Aconite in, J 69 

Apis in, 169 

Arsenicum in, 169 

Belladonna in, 169 

Carbolic acid in, 168 

Definition of, 167 

Graphites in, 169 

Ichthyol in, . . . . - • 169 

Mercurial ointment in, . . .169 

Resorcin in, 169 

Rhus tox. in, 169 

Symptoms of, 167 

Treatment of, . 168 

Ether, sulphuric, 77 

Administration of, 77 

Etherization, rectal, 81 



312 



INDEX. 



Ethyl-chloride, 85 

Etiology of Abscess, 172 

Eucaine, B, 84 

Europhen in Burns, 156 

Excision of ganglion, .... 238 

of Hammer toe, 249 

of Sebaceous cysts, 235 

of the tonsil, . . 207 

of the tonsil, hemorrhage in, . 208 
of the tonsil, treatment of, . . 208 

Exploring needle, .93 

Extraction of teeth, 190 

accidents from, . . ... 191 

Eye, bandage of, 289 

foreign bodies in, 182 

Flannel gloves, 35 

Flax-seed poultice, 134 

Flexible collodion in burns, . 155 
Fluoric acid in ingrowing toe-nail, 248 

Felon, 241 

Fomentations, hot, 135 

Forceps, artery, 64 

Forced flexion in hemorrhage, 56 
Forci-pressure in hemorrhage, . 58 

Ford's suture, 141 

Foreign bodies in the eye, . . 182 

method of removal, 182 

in the ear, 207 

in the ear, treatment of, . . 207 
in the female bladder, . . . 279 
in the female bladder, removal 

of, 279 

in the larynx and trachea, . . 223 
in the larynx and trachea, treat- 
ment of, ... 234 

in the oesophagus 221 

in the oesophagus, removal of, 221 

in the nose, . . 213 

in the tissues, 130 

in the tongue, 193 

in the urethra, 278 

in the rectum, 281 

in the rectum, symptoms of, . 281 
Formalin, 22 



Formaldehyde, ..... . . . 22 

Fracture of the skull, 131 

Friction knot, 137 

Frost bites, 126 

Ichthyol in, . . . . . . 127 

Iodine in, 127 

Menthol in, [27 

Pulsatilla in, 127 

Sulphur in, 127 

Treatment of 126 

Thiol in, . . , 127 

Furuncle, 164 

Felon, 240 

Aluminum in, . . 241 

Asafcetida in. . . . ... 241 

Carbolic acid in, ... . 240 

Fluoric acid in, .... . . 241 

Graphites in, ....... 241 

Hepar sulphur in, 241 

Incision in, 240 

Iodoform oil in, 241 

Mercurius in, 241 

Natrum sulph. in, 241 

Poultices in, 241 

Silicea in, 241 

Symptoms of, .... . . 240 

Treatment of, 240 

Female bladder, foreign bodies 
in, ... . .... 279 

catheter, method of passing, 275 
Fell's method of artificial respira- 
tion, . . . 121 

Feet, sterilization of, 37 

Figure-of-eight bandage of the 

ankle, 299 

of the axilla, 291 

of the elbow, ........ 294 

of the knee, ... 299 

of the neck, 291 

Finger, bandage of, 292 

Cot, 35 

Lock, 246 

Spiral bandage of, 292 

Trigger, 246 

Webbed, 233 



INDEX. 



313 



Fistula, 175 

treatmeut of, 175 

Ganglion, . 238 

Aurum iu, 239 

Causticum in, 239 

Excision of, 238 

Mezereum in, 239 

Phytolacca in, 239 

Silicea in, ^. . . . 239 

Gall bladder, rupture of, ... . 264 

Gas, laughing, 80 

Suffocation from, 123 

Gasoline, 24 

Gauntlet bandage of the hand, . 293 

Gauze, 31 

Bandages, 31 

Carbolized, 30 

Bichloride, 30 

Iodoform, 30 

Pads 25 

Pledgets, 25 

Tampons in epistaxis, . . . 214 
Gayraud's incision, ..... 260 
Gelatine in hemorrhage, .... 63 

General ansesthesia, 68 

Gibney dressing in sprains, . . . 253 
Glacial acetic acid in warts, . . . 234 

Glass catheters, 267 

Gloves, cotton, 35 

flannel, 35 

rubber, 35 

silk 35 

Gold chloride in snake-bite, . . 152 
Goulard's solution in abscess, . . 172 

in Corns, 25 

Graphites in bunion, 251 

in Bursitis,. 238 

in Erysipelas, 169 

in Felon, 241 

in Onychia 242 

Groin, spica bandage of, ... . 300 

Granny knot, 137 

Gum boil, 188 

Treatment of, 189 



Gum catheters, 257 

Gunshot wounds, ...... 149 

Glycerine enemata, 283 



Hagedorn's needles, 
Hallux valgus, 

treatment of, . . . . 
Hamamelis in epistaxis, 
Hammer toe, 

Excision in, 



- - 136 

• ■ 249 

• • 250 
. . 217 

. . 248 

• 249 

Treatment of, 249 

Hand, Gauntlet bandage of, . . 293 
Demi-gauntlet bandage of, . . 293 

Sterilization of, 34 

Harelip suture, 139 

Head, recurrent bandage of, . 287 
Six-tailed bandage of, ... 289 

Heat, ... 24 

Heatstroke, 124 

treatment of, 124 

Heels, blistered, . 246 

Hepar sulphur in felon, .... 241 

in onychia, 242 

in palmar abscess, 242 

in w unds of joints, 231 

Hernia cerebri, 181 

treatment of, 181 

Holocaine, 183 

in Wounds of conjunctiva, . .183 
Horsehair sutures and ligatures, . 28 

sterilization of, 28 

Hot compresses, 135 

Hot dry air baths, technique of, . 101 
Constitutional effects of, . . . 102 
in Sprains, ..... . . 253 

Hot fomentations, 135 

Hot water in hemorrhage,. . . 60 

Housemaid's knee, 236 

Hemorrhage, 53 

Acupressure in, 61 

Angiotribe in, 61 

Alum in, .61 

Arterial, 56 

Aseptic wax in, ...... 60 

Atropine in, 53 



3H 



INDEX. 



Cauterization in, 

Chloroform in, 

Compresses in, . . . 
Constitutional treatment 
Deep sutures in, . . . . 

Digital compression in, . 
Digitalis in, ..... . 

Elastic constriction iu, . 
Ergotine in, . . . . 

in excision of the tonsil, 
Forcipressure in, ... 

Gelatine in, 

Hot water in, . . 

Ligation in, 

Morphine in, 

Nitroglycerine in, . . . 
Park's mixture in, . . . 
Permanent control of, . 
Persulphate of iron in, . 

Position iu, 

Pressure in, 

Resin in, ...... . 

Subsulphate of iron in, 

Strychnia in, 

Styptics in, 

Symptoms of, . . . 

Tannin in, 

Temporal control of, . 
Tourniquet in, ..... 

Torsion in, 

Treatment of capillary, . 

Umbilical, 

Urethral, 

Hepar Sulphur in abscess, 
in alveolar abscess, . . 

in Boils, 

in Bunions, . ... 
in Bursitis. .... 



of 



60 
61 
59 
53 
60 

55 
53 
56 

53 
208 

58 

63 
60 

56 
64 

53 
61 

56 
61 
61 
58 
61 
61 
53 
53 
53 
61 

54 
55 
57 
54 
256 
281 

175 
i8q 

165 
251 
238 



Hourteloup's artificial leech, . . 105 
Howard's method of artificial res- 
piration, . 120 

Hydrastis in Cancrum oris, . . 190 
Hydrochlorate of cocaine, ... 82 
Hydrogen peroxide, 21 



Hyoscyamus in post-operative in- 
sanity . . 128 

Hypericum in brush burns, . . .159 

in Bunion, 251 

in Bursitis, 238 

in Ingrowing nail, . . . . 248 

in Lacerated wounds, .... 149 
in Nerve injuries, ... 233 

in Sprains, 257 

in Tendon dislocation, .... 228 

in Tendon rupture, 228 

in Teuo-synovitis, 230 

Ice, ^ . 85 

Bags, ' ... 135 

Ichthyolin Frostbites, 127 

Ignipuncture, . 115 

Immediate transfusion, . .... 112 

Immovable dressings, 301 

Improvised operating gowns, . . 47 

Incised wounds, 144 

Acouite in, 145 

Arnica in, 145 

of the scalp, 177 

Staphysagria in, 145 

Incision in bursitis, . . . 236 

Chiene's, 218 

in contraction of the palmar 

fascia, 244 

in felon, 240 

in Palmar abscess, 242 

iu Teno-syuovitis, 229 

for Venesection, 104 

Indications for artificial respira- 
tion, . . 117 

for Intubation of the Larynx, . 200 

for Tracheotomy, 203 

Inebriation, 81 

Infected wounds, 143 

Infection, special forms of, . . .164 

of wounds, 49-51 

Inflation, mouth to mouth, . . 120 

Infusion, intra-arterial, . . . .111 

Ingrowing nail, fluoric acid in, . 248 

Hypericum in, 248 



INDEX. 



315 



Monsell's solution iu, . . . . 247 

Silicea in, . . . 248 

Ingrowing toe-nail, 247 

treatment of, 247 

Injections, urethral, 271 

Injuries of the abdomen, .... 263 

Treatment of, 265 

Due to electricity, 162 

of Nerves, 231 

of the Stomach, . ,- w . , 263 

of the Vessels of the chest 

259 
127 
299 
272 

37 
259 



wall, 

Insanity, post-operative, . 
Instep, Spica bandage of, 
Installations, urethral, . . 
Instruments, sterilization of, 
Intercostal arteries, wounds of, 
Internal mammary artery, wounds 

of, 259 

Interrupted suture, 139 

Intestines, rupture of, 263 

Intra-arterial infusion, 11 1 

Intubation of the larynx, . . 199 

After treatment of, 202 

Indications for, 200 

Technique of, . . 200 

Iodine in frost bites, 127 

Iodoform, 23 

in burns, 156 

Collodion, 23 

Emulsion, 23 

Emulsion in bursitis, 237 

Etherial solution of, 23 

Gauze, 30 

Oil in felon, ... .... 241 

Ipecac after anaesthesia, .... 74 

Irrigation of the anterior urethra, 275 

of the Bladder, 276 

of the Vagina, 277 

Valentine's, . 275 

Irritation, counter, ..... 112 

Joints, Wounds of, 230 

Kali iodide in Sprains, 257 



Kidney, lesions of, 264 

Knot, friction, ... . . . 137 

Reef, 136 

Square, 136 

Staff ordshie, 138 

Surgeon's, . . 137 

Knee, figure-of-eight bandage of, .300 

Housemaid's, 236 

Krag-Jorgensen's bullet, .... 149 
Krause's method of skin-grafting, 99 
Kreolin, ... 21 

Laborde's method of artificial 

respiration, 119 

Lacerated wounds, 149 

Aconite in, 149 

Arnica in, 149 

Calendula in, 149 

Hypericum in, 149 

of the scalp, 177 

Lachesis in carbuncle, 167 

in Onychia, 242 

Largin, 23 

Laughing gas, 80 

Larynx, Intubation of, . . . . 199 

Lavage of the Stomach, 95 

Lead water in sprains, . .253 

Le Dentu's tendon sutures, . 226 
La Fort's tendon sutures, . . . 226 

Lejar's tendon sutures, 226 

Lee-Metford bullet, 149 

Leech. American, ....... 105 

Swedish, 105 

Leeching, 105 

Lembert suture, 14 l 

Lesions of the bladder, 264 

of the kidney, 264 

of the spleen, 264 

Lids, wounds of, . . . . 184 

Ligation of arteries, 56 

in hemorrhage, 56 

Ligature, catgut 28 

Erichsen's, 116 

Method of securing, .... 136 
Silk, 28 



3i6 



INDEX. 



Lint, 31 

Lip, carbuncle of, 185 

Local anaesthesia, 82 

Carbolic acid in, 86 

Indications for, 82 

Peroxide of hydrogen in, . . . 86 

Lock finger, 246 

Operation for, 246 

Treatment of, 246 

Lower extremity, spiral reversed 

bandage of, 299 

Lumbar puncture, 90 

technique of, 90 

Lusk's method of skin-grafting, 99 
Lysol, 24 

Mcintosh dressings, 29 

Materials used in bandages, . . 286 
Massage in contraction of the 

palmar fascia, 244 

in Nerve injuries, 233 

of the prostate gland, .... 280 
in Tendon dislocation, .... 228 

Mauser bullet, 149 

Mediate transfusion, in 

Melilotus in epis taxis, .... 217 

Menthol in frost bite, 127 

Mercurius in abscess, 175 

in Alveolar abscess, 189 

in Boils, 165 

in Bunion, 251 

in Bursitis, . . 238 

in Cancrum oris, 190 

in Felon, 241 

in Onychia, 242 

in Ranula, 188 

in Wounds of joints, 231 

Mercury, bichloride of, .... 21 
Mercurial ointment in abscess, . 172 

in erysipelas, 169 

Metal catheters, 267 

Method for irrigating the blad- 
der, 279 

the urethra, 275 

the vagina, 277 



Method of passing bougies, . . . 274 
of passing rectal bougies, . .281 
of removal of foreign bodies 

in the eye, 182 

of securing ligatures, ... . 136 
of securing sutures, .... 136 

Mezereum in ganglion, 239 

Milk enemata, 284 

Minor surgical miscellany, ... 90 
Miscellany, minor surgical, . 90 

Mixture, A. C. K., 79 

Monosulphide of calcium in 

boils, 165 

Monsell's solution in ingrowing 

nail, 247 

Mouth to mouth inflation, . . .120 

Morphine in hemorrhage, . . 53-64 

in Surgical practice, . . .129 

Motion, passive, 102 

Moulded splint, .... 304 

Muscles, dislocation of, .... 228 

Wounds of, 225 

Mustard plaster, 113 

Natrum sulph. in felon, .... 241 
Neck, figure-of-eight bandage of, 291 

Needle, electric, no 

exploring, 93 

Hagedorn's, 136 

Needles and sutures, materials 

used in, 136 

Nerve injury, 231 

Aconite in, 233 

Arnica in, 233 

Electricity in, 233 

Hypericum in, 233 

Massage in, 233 

Rhus tox. in, 233 

Symptoms of, 232 

Treatment of, 232 

Suture, 232 

Nirvanin, . . 85 

Nitrate of silver in Sinus, . . 175 

Nitric acid in boils, 165 

in Warts, 234 



INDEX. 



317 



Nitrous oxide, 80 

Nitro-glycerine in hemorrhage, . 53 

in shock, 67 

Non-penetrating wounds of the 

abdominal wall, 265 

treatment of, 265 

Normal salt solution, 107 

Intra-venous injection of, . . 107 

Preparation of, 108 

Nosopheu, 22 

in Abscess, ... "7 173 

Nose, foreign bodies in, .... 213 

Nutrient enemata, 284 

Nux vomica after anaesthesia, . . 74 

Oakum, 31 

Objections to administration of 

ether 77 

OEsophagus, foreign bodies in, .221 

Oil of cassia in cancrum oris, . . 190 

Oil of cedar in chronic sprain, . 257 

of Gaultheria in cancrum oris, 190 

of hemlock in chronic sprains, 257 

Oiled silk 37 

Onychia, 241 

Alumina in, ... 242 

Causticum in, 242 

Definition of, 241 

Graphites in, 242 

Hepar sulphur in, 242 

Lachesis in, 242 

Mercurius in, 242 

Silicea in, 242 

Sulphur in, 242 

Treatment of, 241 

Operation, Anger's, 248 j 

Diday's, 234 ■ 

for Contraction of the palmar 

fascia, 245 

of the Capillaries, 115 

for Lock finger, 246 

after treatment of, 42 

for Trigger finger, 246 

for Webbed fingers, 243 

Operating gowns, improvised, . 47 



Operator, clothing of, 33 

Opium poisoning, 132 

Orthoform, .85 

Oschner's dressing in sprains, . 255 
Otis's method of treatment of 

abscess, . . 174 

Ox-gall enemata, 283 

Oxygen with anaesthesia, ... 82 

in Shock, 67 

Oxide nitrous, 80 

Oyster broth enemata, 285 

Palmar abscess, 242 

Hepar sulphur in, 242 

Incision in, 242 

Passive motion in, 242 

Treatment of, 242 

Palmar Arch-wounds of, . . 243 

Paper, parchment, 31 

Parchment paper, 31 

Park's mixture in hemorrhage, . 61 

Paronychia, 240 

Passive motion, J02 

in Contraction of the palmar 

fascia, 244 

in palmar abscess, 242 

in Sprains, . . 253 

Pasteur treatment, 153 

Passing the female catheter, . . 275 

Sounds, 273 

Paquelin cautery, 114 

Penetrating wounds of the ab- 
dominal wall, 265 

Peritonsillar abscess, 186 

Peroxide of hydrogen in, . . . 187 

Symptoms of, 186 

Treatment of, 186 

Permanganate of potash, .... 23 
Permanent control of hemor- 
rhage, 56 

Peroxide of hydrogen, ... .21 

in Abscess, 173 

in Brush Burn, 159 

as a Local anaesthetic, .... 86 
in Peritonsillar abscess, . . . 187 



3i8 



INDEX. 



Peroxide of hydrogen in Sinus, 175 
Persulphate of iron in hemor- 
rhage, 61 

Phlebotomy, 103 

Phlegmon, 170 

Definition of, 170 

Symptoms of, 170 

Treatment of, 170 

Phosphorus in epistaxis, . . . .217 
Phytolacca in ganglion, .... 239 
Picric acid in burns, ... . . 155 
Plantago in Alveolar abscess, . . 189 

Plaster, 133 

Mustard, 113 

Resin, 133 

Rubber, adhesive, 133 

Abuses of, 133 

Plaster of Paris jacket, applica- 
tion of, 303 

Dressings, 301 

Position in hemorrhage, .... 61 
Posterior figure-of-eight bandage 

of the chest, 298 

Post-operative insanity, .... 127 
Belladonna in, . . .... 128 

Hyoscyamus in, 128 

Stramonium in, ...... . 128 

Potassium nitrate in Burns, . . . 156 
Permanganate, ....... 23 

Poultices, 133 

Antiseptic, 134 

in Felon, 240 

Flax-seed, 134 

Varieties of, 134 

Powder burns, . - 158 

Powder, dressing, 42 

Preparation of patient for anaes- 
thetic, 68 

of Plaster of Paris dressings, . 301 

of Room for Aseptic operation, 33 

Pressure in hemorrhage, . . . 58-59 

Prognosis of electrical burns, . . 160 

Prostate gland, massage of, . . 280 

Protargol, 23 

Protective, 29 



Protective dressings, ...... 29 

Pulsatilla in epistaxis, . . . . 217 

in Frost bites .127 

Pump, Stomach, 95 

Puncture of the Bladder, .... 270 
Punctured Wounds of the scalp, 177 

Wounds, 146 

Pyrofistine 135 

Quilled suture, 139 

Ranulse and calculi, 187 

Calcarea carb. in, 188 

Mercury in, . . 188 

Sulphur in, . 188 

Symptoms of, 187 

Thuja in, 188 

Treatment of, 187 

Rapid respiration, 8r 

Recurrent bandage of the head, 287 

Rectal bougies, . 281 

etherization, 81 

Rectum, foreign bodies in, . . . 281 
Sterilization of, ....... 37 

Redressing of wounds, . . 49 

Reef knot, .... . . 136 

Regional minor surgery, . . .177 
Remedies in Abscess, .... 175 

Removal of foreign bodies in the 
female bladder, ....... 279 

from the nose, 213 

from the CEsophagus, .... 221 
of Plaster of Paris casts, . . 302 
of Foreign bodies in the 

rectum, 283 

from the urethra, ...... 278 

of sutures, . 142 

of tattoo marks, 128 

Respiration, rapid, 81 

Resection of a rib, ...... 260 

Resin plaster, 133 

Resorcin in hemorrhage, .... 61 
Resorcin in erysipelas, . . . . 169 
Resuscitation after suffocation, 124 
Retained catheter, 270 



INDKX. 



319 



Retropharyngeal abscess, . . .217 

Causes of, .... 217 

Symptoms of, 217 

Treatment of, 217 

Retractors, 32 

Roller bandage, 286 

Rib, resection of, 260 

Room, preparation of, for aseptic 
operation, 33 

Rhinoliths 214 

Causes of, . . . . . w . . . . 214 
Treatment of, 214 

Rhus tox. in burns, 157 

in Carbuncle, 167 

in Erysipelas, 169 

in Nerve injuries, 233 

in Tendon dislocation, .... 228 

in Teno-synovitis, 230 

in Sprains, 257 

Rubber, adhesive plaster, . . . 133 

Catheters 268 

Dam, . . 29 

Gloves, 35 

Sleeves, ... 35 

Tissue, 29 

Rubefacients, 112 

Capsicum as 112 

Rupture of the gall-bladder, . . 264 
of the intestines, 263 

Ruta in Bursitis 238 

in Sprains, 257 

in Bunion, 251 

Salicylic acid in Corns, . . . .251 

Salivary calculi, 187 

glands, abscess of, 208 

Salol, 37 

in sterilization of the bladder, 37 
Salt solution in shock, .... 67 
Scalds of the buccal cavity, . . 198 
Scalp, Contused Wounds of, . . 177 

Incised Wounds of, 177 

Lacerated Wounds of, ... . 177 
Punctured Wounds of, ... . 177 
Wounds, 177 



Scalp wounds, treatment of, . . 178 

Scarification, 105 

Snake-bite, 152 

Sprains, .... 252 

Aconite in, 257 

Arnica in, 257 

Bryonia in, 257 

Chronic, 256 

Conium in 257 

Definition of, 252 

Gibney dressing in, 253 

Hot air bath in, 253 

Hypericum in, 257 

Kali iod. in, 257 

headwater in, 253 

Oschner's dressing in, . . 255 

Passive motion in 253 

Rhus tox in, 257 

Ruta grav. in, 257 

Treatment of, .... . . . 252 

Sprain-fracture, 257 

Staffordshire knot, 138 

Staphysagria in Alveolar Abscess, 1 89 

in Cancrum oris 190 

in Incised wounds, 145 

Stramonium in post-operative in- 
sanity, 128 

Strapping the chest, 262 

the testicle, 280 

Schleich's anaesthetic mixture, 80-84 
Sebaceous cysts, ... . . 235 

excision of, 235 

treatment of, 235 

Seminal vesicles, stripping the, . 280 

Sepsis, . 18 

Seton, . . 114 

Special forms of infection, . . . 164 

Spleen, lesions of, 264 

Sterilization of bladder, ... 36 

of bladder, Salol in, 37 

of the bladder, Urotropin in, . 37 

of feet, , -37 

of Hands, . 34 

of Horse-hair sutures and liga- 
tures 28 



(/ 



w 



320 



INDKX. 



Sterilization of Instruments, . . 37 
of Mucous membrane, .... 36 

of Rectum, 37 

of Silk ligatures, 28 

of Silk-worm gut, 28 

of Skin, 36 

of Urethra, 36 

of Vagina, 36 

Sterilized cotton, 31 

preparation of, 31 

Swedish leech, 105 

Signs of death, 132 

Silicea in Abscess, 175 

in Alveolar Abscess, . ... 189 

in Boils, 165 

in Bunions, 251 

in Bursitis, 23S 

in Carbuncle, 167 

in Felon, 241 

in Ganglion, 239 

in Ingrowing nail, ... . 248 

in Onychia, 242 

in Wounds of joints, 231 

Silk gloves, 35 

ligatures, sterilization of, . . . 28 

Oiled, , 37 

Suture, 28 

Worm gut, 28 

Silver wire, 28 

Sinus, 175 

Bichloride of Mercury in, . 175 

Nitrate of Silver in, 175 

Peroxide of hydrogen in, . . 175 

Zinc chloride in, 175 

Definition of, 175 

Treatment of, 175 

Six-tailed Bandage of the Head, 289 
Skin, sterilization of, . . 36 

grafting, 97 

grafting, Krause's method of, 99 

Lusk's method of, 99 

Thiersch's method of, . . 98 

Spica Bandage of the Groin, . . 300 

of the Instep, 299 

of the Shoulder, 294 



Spica Bandage of the Thumb. . 293 
Spiral Bandage of the Chest, . . 296 
Bandage of the Finger, . . . 292 
Reverse Bandage of the Lower 

extremity, 299 

Reverse Bandage of the Upper 

extremity, 293. 

Splint, Bavarian, 302 

Moulded, 304 

Stings and bites of the tongue, . 194 

treatment of, 195 

Stripping the seminal vesicles, . 280 

Shock, Ammonia in, 67 

Atropine in, . . , 67 

Camphor in, 67 

Nitro-glycerine in, 67 

Oxygen in, 67 

Salt solution in, 67 

Strychnia in, 67 

Veratrum alb. in, 67 

in Electric burn, 160 

Treatment of, 67 

Shoulder, Ascending Spica band- 
age of, 295 

Spica, bandage of, 294 

Soap, green, 36 

plaster, . . : . . . 134 

poultice, 134 

suds, enemata, 283 

Sounds, method of passing, . . 273 

Sponges, 25 

Stomach, injuries of, 263 

lavage of, 95 

Bump, 95 

Tube, ' 95 

Stone searcher, 274 

Skull cap, 287 

Square knot, 136 

Stupes, turpentine, 113 

Subarachnoidean injections of 

Cocaine, 86 

Subcutaneous injection of the 

normal salt solution, . .110 
ligatures in the treatment of 
dilated vessels, 116 



/ 



INDEX. 



,21 



Subcuticular suture, . ... 141 
Subsulphate of iron in hemor- 
rhage, 61 

Suffocation from gas and vapors, 123 

Resuscitation after, 124 

Sulpho carbolate of zinc, .... 22 

Sulphvft- in Corns, -251 

in Frost bite, 127 

in Onychia, 242 

in Ranula, 188 

Sulphuric ether, . . .*" 77 

Sunstroke and heat stroke, . .124 

Treatment of, 125 

Superheated dry air baths, . . .100 
Suprarenal extract in epistaxis, 216 

Surgeon's knot, 137 

Surgical practice, morphine in, . 129 

Pump, Allen's, 107 

Treatment of Abscess, . . . .173 
Suture of arteries, .... 56-64-65 

Buried, . . 140 

Button, 140 

Catgut, 26 

Continuous, 138 

Ford's, 141 

Harelip, 139 

Interrupted, 139 

Lembert, 141 

Method of securing, 136 

of Nerves, 232 

Quilled, 138 

Removal of, 142 

Silk, 28 

Subcuticular, 141 

Twisted, 139 

of Veins, 64 

Strychnia in hemorrhage, ... 53 

in Shock, 67 

Styptics in hemorrhage, . . 53-60 
Sylvester's method of artificial 

respiration, 118 

Symptoms of Abscess 172 

of Adenoid growths 218 

of Anthrax 170 

of Burns of tongue, 19S 



Symptoms of Bursitis, . . . 236- 

of Cancrum oris, 

of Carbuncle, 

of Cerebral hemorrhage, . . . 

of Electrical burns, 

of Epileptic convulsions, . . . 

of Erysipelas, 

of Felon, 

of Foreign bodies in rectum, . 

of Hemorrhage, 

of Nerve injuries, 

of Opium poisoning, 

of Peritonsillar abscess, . . . 

of Phlegmon, 

of Ranula, 

of Retro-pharyngeal abscess, . 

of Syncope, 

of Tendon rupture, 

of Wounds of Brain, 

Syncope, ... 

treatment of, 

Syndactylism, 



-237 
189 
166 
131 
159 
132 

167 
240 
2S1 

53 
232 

132 
1S6 
170 
1S7 
217 

131 

227 

179 
131 
I3t 
233 



Tampons, 31 

Tannic acid in epistaxis, . . . .214 

Tannin in hemorrhage, 61 

in Umbilical hemorrhage, . . . 266 

Tapping the abdomen, 266 

Tattoo marks, 128 

Removal of, 128 

Tracheotomy, 203 

in Abscess of the neck, . . . .212 
after treatment of, . . . 

Indications for, 

Technique of, 

Tubes 

Transfusion, 107 

Immediate, 112 

Mediate, jii 

with blood, in 

With blood, dangers of, . . .111 
Technique of aspiration, .... 93 
of Antiseptic operation, .... 43 
of Aseptic operation, . . . . 43 
of Catheterism, 269 



203 
203 
203 
203 



21 



\S 



^22 



INDKX. 



Technique of Hot dry air baths, 101 
of Intubation of the larynx, . . 200 

of Lumbar puncture, 90 

of Tracheotomy, 203 

of Urethral injections, .... 277 
of Urethral instillations, . . . 272 

of Vaccination, 96 

of Venesection, 103 

Teeth, extraction of the, .... 190 

Temporary control of hemor- 
rhage, 54 

of arterial hemorrhage, .... 54 

Tendon, dislocation of, 228 

Arnica in, 228 

Bryonia in, 228 

Calendula in, 228 

Hypericum in, 228 

Rhus tox. in, 228 

Lengthening, Anderson's 

method of, 226 

Czerny's method of, 227 

Rupture, Arnica in, 228 

Calendula in, 228 

Hypericum in, 22g 

symptoms of, 227 

Sutures of Le Dentu, 226 

of Le Fort, 226 

of Lejars, 226 

Wounds of, 225 

Teno-synovitis 228 

Arnica in, 230 

Bryonia in, 230 

Causes of, 228 

Elastic bandage in, 229 

Hypericum in, 230 

Incisions in, 229 

Rhus tox. in, 230 

Treatment of, 229 

Tent, 32 

Testicle, Strapping the, .... 280 

Thectitis, 238 

Treatment of, 238 

Theory of Antisepsis, 19 

of Asepsis 18 

Thermo cautery, Paquelin, . . .114 



Treatment of abscess of neck, . . 212 
of Abscess of salivary glands, . 209 
of Accidents occurring during 

anaesthesia, 73 

of Accidents occurring during 

chloroform 77 

of Adenoid growths, . .#. . 220 

of Alveolar abscess, 189 

of Anthrax, 170 

of the Apparently drowned, .121 
of Blank cartridge wounds, . . 152 

of Blistered heels, 246 

of Cancrumoris, 189 

of Capillary hemorrhage, . . 54 

of Carbuncle, 166 

of Carbuncle of lip, .... 185 
of Cerebral hemorrhage, . . .131 
of Dislocation of muscles, . . .228 

of Electrical burns, 160 

of Epileptic convulsions, . . . 132 

of Epistaxis 214 

of Excision of tonsils, .... 208 

of Felon, 240 

of Fistula, 175 

of Hallux valgus, ...... 250 

of Hammer toe, 248 

of Heatstroke 124 

of Hernia cerebri, 181 

of Lacerated wounds 147 

of Palmar Abscess, 242 

of Peritonsillar abscess, .... 186 

of Phlegmon, 171 

of Ranula, 187 

of Retro-pharyngeal abscess,. . 217 

of Scalds of tongue, 198 

of Scalp wounds, 178 

of Sebaceous cysts, 235 

of Snake bite, 152 

of Sprains, 252 

of Tendon dislocation, .... 228 

of Teno-synovitis, 229 

of Thectitis, 238 

of Venous hemorrhage, .... 64 

of Warts, 234 

of Webbed fingers, 233 



V 






INDEX. 



Treatment of incised wounds, . 145 

of Ingrowing Nail, 247 

of Infected wounds, 143 

of Injuries of the Abdomen,. . 264 
of Injuries due to Electricity, . 162 

of Rhinoliths 214 

of Sinus, 175 

of Stings and bites of the 

tongue, 195 

of Trigger finger, 246 

of Boils, 164 

of Chronic sprains, . . . . 256 

of Concussion of the chest, . . 258 
of Contraction of the palmar 

fascia, 244 

of Contused wounds, 146 

of Corns, 251 

of Dog bite, 153 

of Erysipelas, 168 

of Foreign bodies in the lar}mx,224 
of Foreign bodies in the 

tongue, 193 

of Frost bites, 126 

of Lock finger, 246 

of Nerve injuries, 232 

of Non-penetrating wounds of 
the abdominal wall, .... 265 

of Onychia, 241 

of Powder burns, 158 

of Shock, 167 

of Tongue tie, .' . . . . . .196 

of Wounds of the brain, . . .179 
of Wounds of Conjunctiva, . . 184 
of Wounds of Internal mam- 
mary artery, 259 

of Wounds of Joints, 230 

of Wounds of Lids, 184 

of Wounds of Muscles, . . . .225 
of Wounds of the palmar arch, 244 
of Wounds of tendons, .... 225 
of Wounds of tongue, .... 192 

of Brush burns, 159 

of Bunion, 250 

of Burns, 154 

of Burns of the tongue, .... 197 



Treatment of Bursitis, .... 237 

of Cutthroat, 210 

of Gum boil, 189 

of Gunshot wounds, 150 

of Sunstroke, 125 

of Tuberculous abscess, . . . .174 
of Umbilical hemorrhage, . . 266 
of Urethral hemorrhage, . . .281 

of Syncope, 131 

Thiersch's method of skin graft- 
ing, 98 

solution, 23 

Thiol in frost bites, 127 

Tincture of Iodine in Abscess, . . 172 
Tissue, foreign bodies in, .... 130 

rubber, 29 

Trigger finger, 246 

Operation for, ........ 246 

Twisted Suture, 139 

Toe-nail, ingrowing, 247 

Webbed, 234 

Tongue, Abscess of, 197 

Burns and Scalds of, 197 

Foreign bodies in, 193 

Stings and bites of, 194 

Tie, 195 

tie, accidents following division 

of, .... 196 

Wounds of, 192 

Tonsils, excision of, 207 

Torsion in hemorrhage, 57 

Tourniquets in hemorrhage, . . 55 

Thuja in ranula, 188 

in Warts, 234 

Thumb, spica bandage of, ... 293 
Tuberculous abscess, treatment 

of, 174 

Tube, stomach, 95 

tracheotomy, 203 

Tupfers, 26 

Turpentine in Burns, .... 156 

Enemata, 283 

Stupes, 113 



Umbilical hemorrhage, 



266 



324 



INDEX. 



Umbilical hemorrghage, Alum in, 266 

Tannin in, 266 

Treatment of, . 266 

Unconsciousness, . . . . • . . .131 

Umbrella probang, 222 

Upper extremity, spiral reverse 

bandage of, 293 

Urotropin, 237 

in Sterilization of the bladder, 37 

Urethra, Foreign bodies in, . . . 278 

Hemorrhage from, 281 

Method of irrigating, .... 275 

Sterilization of, 36 

Injection of, 271 

Urethral injections, 271 

instillations, 272 

Use of bandages, 286 

Ice bags, 135 

Plasters, ■ . 133 

Vaccination 96 

Vagina, irrigation of 277 

Sterilization of, 36 

Valentine irrigator, 275 

Vapors, suffocation from, . . . .123 

Veins, suture of, 64 

Venice turpentine in corns, . .251 
Veratrum album in burns, . . . 157 

after Anaesthesia, 75 

in Shock, 67 

Venesection, 103 

Technique of, 103 

Incisions for, 104 

Velpeau Bandage, 296 

Venous hemorrhage, treatment 

of, 64 

Vesicants, 113 

Vesicant, Ammonia as, . . . . 113 

Chloroform as a, 113 

Vessels of the chest wall, in- 
juries of, 259 

Veratrum viride in bursitis, . . 238 

Warts, 234 

Antimouium crud. in, . . . 235 



Warts, Calcarea in, 235 

Causticum in, 235 

Chromic acid in, 234 

Definition of, 234 

Dulcamara in, 235 

Electric needles in the treat- 
ment of, 234 

Glacial acetic acid in, .... 234 

Nitric acid in, 234 

Thuja in, 234 

Treatment of, 234 

Web catheters, 267 

Webbed fingers, 233 

Operation for, 233 

Treatment of, . . 233 

Toes, 234 

Wet cupping, 107 

Dressings, 29 

Whiskey enemata, 285 

Wood wool,.. 31 

Wounds of the abdominal wall, . 265 

of the Brain, 179 

of Brain, Symptoms of, . . . .179 
of Brain, treatment of, . . . .179 

Blank cartridge, 152 

of the Conjunctiva, . ..... 183 

of the Conjunctiva, Holocaine 

in, 183 

of the Conjunctiva, treatment 

of, 184 

Contused, 146 

Dissection, ... 144 

Drainage of , 51 

Incised, 144 

Infected, 143 

Infection 49-5 1 

Lacerated, 149 

of Intercostal arteries, .... 259 
of Internal Mammary artery, . 259 

of joints, 230 

Aconite in, ■ . 231 

Calendula in, 231 

China in, 231 

Hepar sulphur in, 231 

Mercurius in, 231 



INDEX. 



325 



Wounds of Joints, Silicea in, . .231 Wounds of the Scalp, 177 



of the lids 184 

of the Lids, Boric acid in , . . 184 

Cold Compresses in, 184 

treatment of, 184 

of Muscles, 225 

of Muscles, treatment of, . . . 225 

of the Palmar arch, 243 

Punctured, 146 

Redressing of, 49 



of Tendons, 225 

of the tongue, 192 

of the Tongue, treatment of, . 192 
Wyeth's beef -juice enemata, . . 285 

X-Ray burns, 161 

Zinc Chloride in Sinus, 175 

Sulpho-carbolate of, 22 



■rV 




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